NATIONAL AIDS CONTROL PROGRAMME
NATIONAL COMPREHENSIVE GUIDELINES ON HIV TESTING SERVICES
Ministry of Health, Community Development Gender Elderly and Children
National AIDS Control Programme (NACP)
P.O. Box 743,
40478 DODOMA.
Website: www.nacp.go.tz
Email:
info@nacp.go.tz
Suggested citation: National AIDS Control Programme: National Guidelines for HIV Testing
Services in Tanzania: Third Edition; NACP; 2019.
©2019 Ministry of Health, Community Development, Gender, Elderly and Children, Tanzania
Any part of these HTS guidelines can be reproduced or translated provided the Ministry of
Health, Community Development, Gender, Elderly and Children is acknowledged. Comments
and inquiries should be addressed to:
The Permanent Secretary,
Ministry of Health, Community Development, Gender, Elderly and Children,
P.O. Box 743,
40478 DODOMA
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TABLE OF CONTENTS
ABBREVIATIONS AND ACRONYMS...................................................................................... vii
FOREWORD............................................................................................................................ix
ACKNOWLEDGEMENT............................................................................................................x
DEFINITION OF TERMS..........................................................................................................xi
EXECUTIVE SUMMARY ....................................................................................................... xiv
CHAPTER ONE: INTRODUCTION........................................................................................... 1
1.1
Background............................................................................................................. 1
1.2
Evolution of HTS in Tanzania................................................................................... 1
1.3
Challenges in HTS in the Context of the UNAIDS “90 -90 -90” Strategy................ 1
1.4
Justification for the Revised Guidelines.................................................................. 2
1.5
Goal and Objectives of the HTS Guidelines............................................................ 2
1.6
Target Audience....................................................................................................... 2
1.7
The Development of the HTS Guidelines................................................................ 3
CHAPTER TWO: CORE PRINCIPLES OF HIV TESTING SERVICES...................................... 4
2.1
Counselling.............................................................................................................. 4
2.2
Consent................................................................................................................... 4
2.3
Confidentiality.......................................................................................................... 5
2.5
Connection to services............................................................................................ 6
CHAPTER THREE: HIV TESTING SERVICES (HTS) PACKAGE.............................................. 8
3.1
Promotion of HIV Testing Services.......................................................................... 8
3.2
Creating an Enabling Environment........................................................................ 10
3.3
Pre-Test Sessions.................................................................................................. 10
3.4
HIV Testing............................................................................................................. 12
3.5
Post Test Counselling Session.............................................................................. 12
3.6
Disclosure of HIV Status........................................................................................ 17
3.7
Linkage to Care, Treatment and Support Services................................................ 17
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CHAPTER FOUR: HTS DELIVERY APPROACHES AND SETTINGS.................................... 20
4.1
Approaches and Settings for HTS Delivery in Tanzania........................................ 20
4.1.1
Provider-Initiated HIV Testing and Counselling (PITC).......................................... 20
4.1.2
Client-Initiated HIV Testing and Counselling (CITC).............................................. 22
4.1.3
Community Based HIV Testing Services (CBHTS)................................................ 23
4.1.4
Index client and partner notification model........................................................... 23
4.1.5
HTS approaches for KVPs..................................................................................... 24
4.2
Integrating Community –Based HTS..................................................................... 25
4.3
HTS in Workplace Settings.................................................................................... 25
4.4
Health Care providers and Risk of exposure to HIV.............................................. 26
4.5
HIV Self-Testing..................................................................................................... 26
4.6
Other HIV Testing Approaches.............................................................................. 26
4.6.2
HIV testing of blood and tissue donors................................................................. 27
CHAPTER FIVE: PRIORITY POPULATIONS.......................................................................... 28
5.1
Key and Vulnerable Populations............................................................................ 28
5.2
Infants and Children.............................................................................................. 28
5.3
Adolescents........................................................................................................... 28
5.4
HTS for Orphans and Vulnerable Children (OVC).................................................. 29
5.5
Pregnant Women................................................................................................... 29
5.6
Men........................................................................................................................ 29
5.7
Couples and Partners............................................................................................ 30
5.8
Other Populations at Higher Risk of HIV Infection................................................ 30
CHAPTER SIX: HIV TESTING STRATEGIES FOR DIAGNOSIS............................................. 34
6.1
Indications for HIV Testing..................................................................................... 34
6.2
Testing Strategy for Diagnosis of HIV in Adults and Children
Aged 18 Months or Older...................................................................................... 34
6.6
Managing and documenting HIV Test Results...................................................... 37
6.7
Retesting............................................................................................................... 38
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6.8
Retesting to validate HIV-seropositive status prior to ART initiation..................... 38
6.9
Infection Prevention & Control and Waste Management...................................... 40
6.10
HIV Recent Infection Surveillance......................................................................... 42
CHAPTER SEVEN: QUALITY ASSURANCE AND QUALITY IMPROVEMENT OF HTS........ 43
7.1
The Role of the NHLQATC in HTS......................................................................... 43
7.2
Quality Assurance for HIV Testing Services.......................................................... 44
7.3
Quality Control (QC).............................................................................................. 44
7.4
Regulation on HIV Diagnostics.............................................................................. 46
7.5
Site Audit, Certification, Accreditation and De-certification.................................. 47
7.6
Quality Assurance for HIV Counselling.................................................................. 48
7.7
Quality Assurance for Logistics Management....................................................... 48
7.8
Quality Improvement Teams (QITs) for HTS........................................................... 48
CHAPTER EIGHT: HIV POST TEST CLUBS SERVICES........................................................ 50
8.1
Rationale for HIV Post Test Clubs......................................................................... 50
8.2
Establishment of HIV Post Test Clubs................................................................... 50
8.3
Types of HIV Post Test Clubs................................................................................ 50
8.4
Age categorization of HPTCs................................................................................ 52
8.5
HPTC Leadership.................................................................................................. 53
8.6
Monitoring and Evaluation of HIV Post Test Clubs................................................ 53
CHAPTER NINE: HUMAN RESOURCES FOR HIV TESTING SERVICES............................. 54
9.1
Basic Educational and Ethical Requirements for HTS Providers.......................... 54
9.2
Training of HTS providers...................................................................................... 54
9.3
Coordination and Harmonisation of HTS Training................................................. 56
9.4
Comprehensive Supportive Supervision and Mentoring....................................... 56
9.5
HTS Providers Professional Growth and Development......................................... 57
9.6
Occupational Health and Safety............................................................................ 57
9.7
Task Sharing of HTS: Increasing the Scope of Trained Workers........................... 57
9.8
Roles and Responsibility of the personnel providing HTS.................................... 58
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CHAPTER TEN: COMMODITY MANAGEMENT FOR HTS................................................... 59
10.1
Required HTS Supplies......................................................................................... 60
10.2
HIV Test Kits.......................................................................................................... 60
10.3
Quantification........................................................................................................ 61
10.4
Procurement.......................................................................................................... 62
10.5
Receiving, Storage & Distribution.......................................................................... 62
10.6
Monitoring & Evaluation of HTS Commodities...................................................... 62
CHAPTER ELEVEN: MONITORING AND EVALUATION........................................................ 64
11.1
HTS Data Sources................................................................................................. 64
11.2
Data Collection...................................................................................................... 64
11.3
Data Compilation................................................................................................... 65
11.4
Data Reporting and Feedback.............................................................................. 65
11.5
Data Analysis and Interpretation........................................................................... 65
11.6
Data Use and Sharing........................................................................................... 68
11.7
Documentation...................................................................................................... 69
11.8
Data Storage and Security.................................................................................... 70
11.9
HTS Target Setting................................................................................................ 70
11.10 Monitoring and Evaluation of HIV Post Test Clubs................................................ 71
11.11 Monitoring and Evaluation of essential HTS Commodities................................... 72
CHAPTER TWELVE: IMPLEMENTATION FRAMEWORK....................................................... 73
12.1
National Level........................................................................................................ 73
12.2
Regional Level....................................................................................................... 74
12.3
District Level.......................................................................................................... 75
12.4
Facility Level.......................................................................................................... 75
12.5
Roles and responsibilities of HTS providers at community level.......................... 76
12.6
HIV Testing and Counselling Focal persons.......................................................... 76
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List of Tables
Table 6.1: Retesting Messages for individuals who test HIV Negative ................................. 40
Table 10.1: The Current Recommended HIV Test Kits……………......................................... 61
Table 11.1: HTS Data Compilation ....................................................................................... 66
List of Figures
Figure 3.1: HIV Testing Service Package ................................................................................ 8
Figure 3.2 Post Test Linkages to Treatment Care and Support Services .............................. 18
Figure 4.1 The main HTS Approaches and Settings in Tanzania ........................................... 21
Figure 6.1 The sequence of HIV tests in Serial Testing Strategy .......................................... 35
Figure 6.2: HIV testing Algorithm for Infants and young children ......................................... 39
Figure 10.1 Logistics Management Flowchart for HTS Supplies .....................................…. 59
Figure 11.1: M&E Data Flow and Information system for HTS in Tanzania ........................... 68
List of Boxes
Box 3.1 Vaccine Induced Sero-Positivity (VISP)..................................................................... 17
Box 11.1 Categories for disaggregation of variables recommended by WHO...................... 67
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ABBREVIATIONS AND ACRONYMS
AIDS
Acquired Immune Deficiency Syndrome
ANC
Antenatal Clinic
ART
Anti-Retroviral Therapy
AYWG
Adolescents, Young Women and Girls
CDC
Centres for Disease Control and Prevention
CICT
Client-initiated Counselling and Testing
CTC
Care and Treatment Clinic
DNA
Deoxyribonucleic Acid
ELISA
Enzyme-Linked Immunosorbent Assay
EMTCT
Elimination of Mother-to-Child Transmission
EQA
External Quality Assessment
EPI
Expanded Programme on Immunisation
HBV
Hepatitis B Virus
HCV
Hepatitis C Virus
HIV
Human Immunodeficiency Virus
HIVST
HIV Self-testing
HTS
HIV Testing Services
IPT
Isoniazid Preventive Treatment
MAT
Methadone Assisted Therapy
MCH
Maternal and Child Health
M&E
Monitoring and Evaluation
MOHCDGEC Ministry of Health, Community Development, Gender, Elderly and Children
MSM
Men who have Sex with Men
NACP
National AIDS Control Programme
NHL-QATC
National Health Laboratory Quality Assurance Training Center
NGO
Non-Governmental Organization
OST
Opiod Substitution Therapy
PCR
Polymerase Chain Reaction
PEP
Post-Exposure Prophylaxis
PHC
Primary Health Care
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PITC
Provider-Initiated Testing and Counselling
PMTCT
Prevention of Mother-To-Child Transmission
PPV
Positive Predictive Value
PrEP
Pre-Exposure Prophylaxis
PT
Proficiency Testing
PWID
People Who Inject Drugs
PWUD
People Who Use Drugs
QA
Quality Assurance
QC
Quality Control
RDT
Rapid Diagnostic Test
RMNCH
Reproductive Maternal Newborn and Child Health
RNA
Ribonucleic Acid
SBCC
Social and Behaviour Change Communication
SRH
Sexual and Reproductive Health
SOP
Standard Operating Procedure
STI
Sexually Transmitted Infection
TB
Tuberculosis
UN
United Nations
UNAIDS
Joint United Nations Programme on HIV/AIDS
UNDP
United Nations Development Programme
UNFPA
United Nations Population Fund
UNICEF
United Nations Children’s Fund
USAID
United States Agency for International Development
VCT
Voluntary Counselling and Testing
VMMC
Voluntary Medical Male Circumcision
WHO
World Health Organization
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FOREWORD
The Ministry of Health Community Development Gender Elderly and Children recognizes
HIV testing services as a critical entry point to HIV care, treatment, support and prevention
services. It is expected that when people know their HIV status, they will make an informed
choice on HIV prevention or if positive, access other services. In the country, HIV testing
service has been available since 1989 and is used primarily for screening blood supplies, and
for diagnosis of HIV and AIDS.
These guidelines provide a framework for effective action to facilitate access to safe and ethical
testing services for different population groups. The implementation of the a comprehensive
approach, known as HIV Testing Services (HTS) is cardinal as an effective package of services
that diminishes the impact of the HIV epidemic in our country. All forms of HTS adhere to
the 5Cs: Confidentiality, Counselling, Consent, Correct results and Connection, or linkage
to care, with all based within a human right context. In addition to the 5Cs, however, the
MOHCDGEC emphasizes the use of a variety of approaches to HTS that will reduce the
number of missed opportunities. These include Provider-Initiated Testing and Counselling
testing, Couple counselling and testing, Index testing, and infant and children counselling and
testing in alignment to the revised WHO guidelines. Furthermore, these guidelines accentuate
on the continual provision of integrated HTS service at all levels of the public and private
health service delivery system.
The HTS Providers, managers and other stakeholders at all levels are required to make
extensive use of these guidelines. They are also urged to provide to the MOHCDGEC any
feedback that might be useful for the implementation of future editions of the guidelines.
Dr. Zainab A. S. Chaula
PERMANENT SECRETARY (HEALTH)
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ACKNOWLEDGEMENT
The National Comprehensive Guidelines on HIV Testing Services 2019, is the end result of a
participatory process involving numerous stakeholders from various Ministries, civil society
and non-governmental organizations as well as international agencies.
The Ministry of Health, Community Development, Gender, Elderly and Children (MOHCDGEC)
appreciates and acknowledges the valuable technical and financial assistance from the World
Health Organization (WHO) Tanzania, PEPFAR Tanzania through Centers for Disease Control
and Prevention (CDC), Department of Defense (DOD), United States Aid for International
Development (USAID) and their implementing partners. Moreover, much appreciation on the
technical inputs of PEPFAR Tanzania’s HIV Case Identification and Linkage Technical Working
Group led by Dr. Oscar E. Rwabiyago.
I would like to appreciate the excellent coordination and support of Ms. Peris Urasa, without
her commitment and dedication, it would have been very difficult to accomplish this task.
The expert facilitation and support provided by the Consultants, Dr. Elizabeth Marum, and Dr.
Benedicta Mduma cannot go without being mentioned.
For the coordination during the revision process, MOHCDGEC thanks the National AIDS
Control Program’s management, in particular, Dr. Angela Ramadhani, Program Manager; and
HIV Prevention Unit staff, led by Dr. Gissenge J.I Lija.
The MOHCDGEC extends special thanks to all the individuals for providing support and
technical expertise towards the content and finalization of this document. Wide consultation
and partnership in the development of these revised guidelines will go a long way to ensure
the success of the rollout and uptake of the guidance included in the document.
Prof. Muhammad Bakari Kambi
Chief Medical Officer
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DEFINITION OF TERMS
Accreditation is a procedure by which an authoritative body gives formal recognition that an
organization/individual is competent to carry out specific task1
Certification refers to the action or process of providing an individual or institution with an
official document attesting to a status or level of achievement.
Early infant diagnosis is the testing of infants to determine their HIV status, given that HIV
can be acquired in utero (during pregnancy), per partum (during delivery), or postpartum (after
delivery through breastfeeding), or via parenteral exposure.
External quality assessment scheme is an inter-laboratory comparison to determine if the
HIV testing service can provide correct test results and diagnosis.
External quality assessment is the monitoring of performance through direct observation and
supervision or inter-laboratory comparisons by participating in an external quality assessment
scheme (sometimes known as proficiency testing).
HIV self-Testing (HIVST) is a process in which an individual collects his or her specimen (Oral
fluid or blood) and then performs a test and interprets the test result often in private. Both
reactive and non-reactive test results must be followed by additional HIV testing services
HIV Testing Services (HTS) comprise a full range of services that a client is offered together
with HIV testing. These include counselling (pre and post testing); linkage to appropriate HIV
prevention, care and treatment and support; and coordination with laboratory services to
support quality assurance and delivery of correct results.
High and low volume sites refer to testing sites that perform 25 HIV tests in a day and less
than 25 HIV tests in a day, respectively.
Index testing refer to a focused HIV Testing Service approach in which the sexual partners,
partners of drug users and family members (including children) of people diagnosed with HIV
are offered HIV testing services. It is also referred to as index-case or index patient HIV testing.
Internal Quality Control is the process or mechanism to detect, reduce and correct deficiencies
in a laboratory internal analytical process prior to release of patient results, in order to improve
the quality of the results reported. The appearance of a control line for HIV Rapid Diagnostic
Test is an example of a passed internal QC.
Invalid HIV test result is a test result obtained from a device that does not have a control line.
Key and Vulnerable Populations (KVPs) are groups of people who, due to specific high-risk
behaviour, are at increased risk of contracting HIV, irrespective of the epidemic type or local
context. In Tanzania, KVPs include: 1) men who have sex with men, 2) people who inject
drugs, 3) sex workers 4) people in prison and other closed settings.
1
Modified from ISO/IEC17000(refer to POTC guideline)
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Men who have sex with men refer to all men who engage in sexual and/or romantic relations
with other men.
Non-reactive result refers to an HIV antibody or HIV antigen/antibody test result that does not
show a reaction to indicate the presence of HIV antibodies and/or antigen.
Pre-test information is a dialogue during which accurate information is provided by a trained
HIV Testing Service provider or health worker before an HIV test is performed.
Proficiency testing is the testing of unknown samples sent to a testing point or laboratory by
an approved program. It is used to verify the accuracy and reliability of the testing point or
laboratory.
Quality assurance is any systematic process of determining whether a product or service
meets a specified requirement (appearance of a control line for HIV RDTs is an example of a
passed internal QC.)
Quality control is an assessment of product compliance with stated requirements.
Quality improvement is an approach to the study and improvement of the processes of
providing health care services to meet client needs.
Quality management system is a systematic process-oriented approach to meet quality
objectives.
Reactive result refers to an HIV antibody or HIV antigen/antibody test result that shows a
reaction to indicate the presence of HIV-1/2 antibodies or p24 antigen.
Repeat testing refers to a situation where additional testing is performed for an individual
immediately following a first test during the same testing visit due to inconclusive or discordant
test results; the same assays are used and, where possible, the same specimen.
Retesting refers to certain situations where individuals should be tested after a defined period
of time for example in the case of inconclusive test results, for HIV-negative individuals with
recent or on-going risk of exposure, and HIV-positive individuals before they are enrolled in
care and initiate treatment.
Rapid diagnostic test (RDT) refers to in-vitro diagnostics of immunochromatographic or
immune filtration formats for the detection of HIV-1/2 antibodies and/or HIV p24 antigen.
Sensitivity denotes the probability that an HIV assay/algorithm will correctly identify all
specimens that contain HIV-1/2 antibodies and/or HIV p24 antigen.
Specificity denotes the probability of the assay/algorithm to correctly detect specimens that
do not contain HIV-1/2 antibodies and/or HIV-1 p24 antigen.
Sero-discordant couple refers to a couple with conflicting (different) HIV test results, where
one partner is HIV-positive and the other is HIV-negative.
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Task sharing is the rational redistribution of tasks and expanded scope of work among
different cadres of health-care providers, such as trained workers.
Testing strategy is a testing approach used to meet a specific need, such as for blood safety,
surveillance and/or diagnosis.
Testing algorithm is the combination and sequence of specific assays or tests used in a given
HIV testing strategy as approved by the MOHCDGEC.
Window period is the period between HIV-infection and the detection of HIV-1/2 antibodies
using a serological test.
People who inject drugs refer to people who inject psychotropic (or psychoactive) substances
for non-medical purposes.
People who use drugs include people who use psychotropic substances through any route
of administration, including intravenous, oral, inhalation, transmucosal (sublingual rectal,
intranasal) or transdermal.
Sex workers include female and male individuals who receive money or goods in exchange
for sexual services (usually as the main source of income).
Vulnerable populations (VPs) include adolescents and young women, orphans, street children,
people with disabilities, migrant and mobile workers.
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EXECUTIVE SUMMARY
The Tanzania HIV Impact Survey (THIS) conducted in 2016-17, revealed that the prevalence of
HIV among adults aged 15 to 49 years is 4.7 percent. The HIV prevalence was higher among
adult females (6.2 percent) than males (3.1 percent). According to these results, there are
approximately 1.4 million people living with HIV (PLHIV) in Tanzania and only 61% of them
know their HIV positive status. This depicts an HIV positive identification gap of approximately
29% for Tanzania to attain the Joint United Nations Programme on HIV/AIDS (UNAIDs) first
of the 90-90-90 target, whereby 90% of PLHIVs must be identified and linked to HIV services
by 2020.
These HTS guidelines were developed to provide guidance on strengthening HIV testing
approaches that will enhance uptake, equitable access and coverage of HTS. The guidelines
contain several new recommendations aimed to improve on the previous practices in Tanzania.
These include:
1. Giving more attention to key populations and vulnerable groups: Special efforts should
be made to ensure that key populations and vulnerable persons have access to HIV
testing services, and these services will be provided without discrimination or stigma.
2. Index client testing: HTS Providers will ask people diagnosed with HIV about their sexual
partners, drug injecting partners and biological children, and with consent of the HIV
positive client, these partners and children will be offered voluntary HIV testing.
3. Task Sharing: Engaging other medical and non-medical cadres in the health sector on
HIV Testing Services.
4. Testing for verification: Persons who test HIV positive should be re-tested prior to ART
initiation to rule out misdiagnosis.
5. “Window period” re-testing: For most people who test non-reactive or negative, there
is no need for additional re-testing to rule out being in the window period. However,
those persons who test non-reactive but report recent exposure or recent risk of getting
infected with HIV, should be told to return for re-testing in 4 weeks.
6. Quality assurance and Improvement for HIV testing: This has been re-emphasized in
this guideline as a key strategy to ensure quality HTS and correct HIV diagnosis for each
individual accessing these services.
7. Inconclusive results: Persons who test reactive on the first test and non-reactive on
the second test are considered to have inconclusive results and should be tested again
on same setting/day using the approved national testing algorithm. If the repeat tests
remain different, this is called inconclusive and these persons should return for repeat
testing after 14 days.
8. Correct recording and timely submission of data: This is an essential component of a
strong HTS programme. Health facilities that provide HTS should ensure that HIV test
results are recorded accurately and data submitted on time.
9. Service Delivery Models for differentiated HIV services: These models aim to reach
different population groups with appropriate HTS.
10. HIV Self-Testing: These guidelines mention about the prospect of adopting HIV Selftesting interventions as a tool to identify PLHIV.
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CHAPTER ONE: INTRODUCTION
1.1
Background
The HIV epidemic in Tanzania, since the first reported case in 1983, continues to represent
a major disease burden. The country has a generalized stable epidemic with estimated 4.7
% of adult population to be living with HIV in 20172. However, the burden of the epidemic
varies considerably between different geographical regions, sex and population groups. HIV
prevalence is higher in sub-groups such as people who inject drugs (PWID) (16-51%)3, men
who have sex with men (MSM) (22-42%)4, and mobile populations and sex workers (14-35%)5.
Women are disproportionally more affected, with an HIV prevalence of 6.2% versus 3.1%
among men2.
HIV testing is a critical entry point to HIV prevention, care, treatment and support services. The
Tanzania HIV Impact Survey (THIS) conducted in 2016-17, revealed that only 61% of People
Living with HIV know their HIV positive status2. This depicts a big gap on HIV diagnosis of
approximately 29% in order for Tanzania to attain the UNAIDS 90-90-90 targets by 2020,
which translate as 90 per cent of PLHIV know their HIV status, 90 per cent of these testing
HIV positive have been enrolled into and access antiretroviral treatment and 90 per cent of
those taking ARVs have sustainable viral suppression i.e. a viral load more than 1000 copies/
millilitre. Similarly, the country has a goal of 90% of PLHIV to be aware of their HIV positive
status by 2020 as outlined in the Health Sector Strategic Plan IV.
1.2
Evolution of HTS in Tanzania
HIV Testing Services were initiated in Tanzania in 1989 as Voluntary Counselling and Testing
(VCT) and are now commonly known as Client Initiated Testing and Counselling (CICT). The
National Guidelines for VCT were developed in 20056. Following the introduction of ARV in
2004, additional/new HIV testing approaches were instituted, and the HIV testing guidelines
were revised in 2013.
1.3
Challenges in HTS in the Context of the UNAIDS “90 -90 -90” Strategy
The following challenges are foreseen in the implementation of HTS in the context of the
UNAIDS “90-90-90” Strategy. People’s knowledge of their HIV status through HIV testing
services (HTS) is crucial to the success of the HIV response. However, the following challenges
will need to be addressed for the success of the programme:
· Low access of HTS for different population groups, different age and sexual groups and
in different geographical areas
2
3
4
5
6
Preliminary Summary Findings: Tanzania HIV Impact Survey 2016-17
The United Republic of Tanzania, Ministry of Health and Social Welfare; national aids control programme and
Muhimbili university of Health and allied sciences, Dar es salaam. Integrated Bio-Behavioral Survey Among
People Who Inject Drugs in Dar es Salaam. April 16, 2014
Leshabari et. A; Prevalence of the Human Immunodeficiency Virus, other sexually transmitted infections, and
health-related perceptions, reflections, experiences and practices among men having sex with men in Dar es
Salaam,2013
National AIDS Control Programme; A study of Female Sex Workers in seven Regions: Dar es Salaam, Iringa,
Mbeya, Mwanza, Shinyanga, Tabora and Mara. A Report published in 2014 (ISBN 978-9987-650-83-5)
National Guidelines for Voluntary Counselling and Testing, 2005
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· Late or delayed linkage to prevention, care, treatment and support.
· Missed opportunities for increasing HTS coverage through integration with other services.
· Suboptimal quality of HIV testing services.
1.4
Justification for the Revised Guidelines
Tanzania has adopted UNAIDS’ 90–90–90 strategy, which calls for 90% of all people living
with HIV to be diagnosed, 90% of people living with HIV who are diagnosed to receive ART
and 90% of those on ART to have a suppressed viral load by 2020. As the main entry point
for the HIV continuum of care is through HIV testing it is of concern that only 52% of PLHIV
have been diagnosed, there is therefore urgency for increased availability of HTS services.
Revising the HTS guidelines in line with global guidance and renewing emphasis on quality,
efficiency, yield and linkages is a prerequisite for the country to attain stated targets. A variety
of HTS modalities should be utilised to reach targeted populations in different settings. This
policy guideline provides a framework for all HTS modalities that should be implemented in
the country.
1.5
Goal and Objectives of the HTS Guidelines
The primary goal of the updated HTS guideline is to provide consolidated guidance for a
national HIV approaches to HIV testing services.
Specific Objectives
1. Provide comprehensive evidence-based policy guidance for the delivery of HTS, using a
mix of approaches appropriate to the Tanzanian context.
2. Provide guidance to ensure the delivery of accurate test results and strengthen quality
assurance for HTS.
3. Define HTS package for key and vulnerable populations who are societal marginalized
and culturally stigmatized.
4. Offer guidance on scaling up targeted community-based approaches and services
delivered by HTS trained health care providers.
5. Provide guidance for strengthening referral and linkages to prevention, care and treatment
and other post-test services.
6. Outline data collection, reporting mechanisms and utilization.
7. Describe the responsibilities of various players in HTS guidelines implementation and
monitoring
1.6
Target Audience
This document is intended for use by several institutions and individuals, including the
following:
i) HIV and HTS policy makers and HTS service providers at national, regional, district and
community levels;
ii) Health facility management teams in public or private health facilities;
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iii) HTS providers including laboratory managers and laboratory focal persons for HIV testing
and quality services and their supervisors in all settings (facility and community based)
and their respective organisations;
iv) HIV focal persons in all Ministries, private sector, academia and implementers of work
place based interventions.
v) Ministerial departments/units directly involved in HIV and AIDS prevention, care, treatment
and support services in different sectors.
vi) Development partners and donors, particularly their support in the dissemination and rollout of these guidelines in collaboration with their implementing partners;
1.7
The Development of the HTS Guidelines
The HTS guidelines were developed through a consultative process led by the MOHCDGEC.
Field visits (review of progress reports, in-depth interviews and observation) provided evidence
on existing HTS best practices in the country. The drafting of the guidelines was also informed
by the Health Sector HIV/AIDS Strategic Plan IV7, the Differentiated Service Delivery Models
Initiative8, the National Care and Treatment Guidelines9, the KVP Guidelines10, other key
Government policy documents and the 2015 World Health Organization HIV Testing Services
guidelines. [11,12;13,] HTS guidelines from selected neighbouring countries available online were
also very informative.[14,15,16;17, 18 ]
7
8
9
10
11
12
13
14
15
16
17
18
URT, Health Sector HIV/AIDS Strategic Plan IV, 2017
URT, PEPFAR, I-TECH -Mapping HIV Service delivery Models in TANZANIA, 2016.
URT, MOHCDGEC, NACP, National Guidelines For The Management of HIV and AIDS Sixth Edition, 2017
URT, MOHCDGEC, NACP, National Guidelines for Comprehensive Package of HIV Interventions for Key
Populations.
Tanzania Third National Multi-sectoral Strategic Framework for HIV and AIDS (NMSF III) 2013/14-2017/18
URT- MOHCDGEC, Task Sharing Policy Guidelines for Health Sector Services in Tanzania, January 2016
URT- MOHCDGEC, NACP, National Guidelines for Community Based HIV and AIDS Services.
Ministry of Health, Kenya. NASCOP; Guidelines for HIV Testing Services in Kenya. Nairobi: 2015.
Uganda. Ministry of Health. 2003. Uganda national policy guidelines for HIV voluntary counseling and testing.
Kampala: Ministry of Health.
Ministry of Health Malawi, HIV Testing Services Guidelines, 2016
Republic of South Africa, Health Department; National HIV Testing Services: Policy 2016
URT, MOHCDGEG National HIV rapid tester’s certification framework 2017
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CHAPTER TWO: CORE PRINCIPLES OF HIV TESTING SERVICES
Preamble
HIV testing services shall be conducted with the client in mind and in the client’s best interests,
in line with national and international standards for health care service delivery and human
rights principles. HTS shall respond to the needs and risks of clients or patients. In view of
that, all HTS shall adhere to five C core principles of HTS namely: Counselling, Consent,
Confidentiality, Correct results and Connection.
2.1
Counselling
Appropriate and effective counselling is an important catalyst for encouraging behaviour
change by an individual who after learning her/his HIV status, is supported to seek referral to
other HIV prevention, treatment, care and support services.
Therefore, all HTS providers shall ensure that:
· All HTS include accurate and sufficient pre and post-test counselling sessions.
· The Pre-test counselling is provided in a one-on-one or group setting, but all clients or
patients should have the opportunity to ask questions in a private setting.
· HIV testing must be followed by appropriate and high quality post-test counselling based
on the HIV test results. It should address the unique needs and risks of the HTS clients
or patients.
When HTS is declined
When a client or patient refuses to give consent for HTS, the HTS provider shall:
· The client shall not be denied access to other health services.
· Record the decision to decline in the HTS register so that a discussion of HTS can be reinitiated at subsequent visits to the health facility.
Counselling Couples
When counselling couples for HTS, the providers shall encourage both partners to:
· Be counselled and receive their test results together.
· Keep each other’s test result private and confidential.
· Discuss HIV risk concerns together and support one another.
2.2
Consent
All clients or patients receiving HTS must be provided with sufficient information about HIV
testing and counselling so that they may give their explicit and voluntary informed consent to
receive these services. The information should generally include:
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· Benefits and implications of knowing one’s HIV status and/or the reasons for recommending
HTS.
· HTS process and procedures.
· Recognition of the client’s right to withdraw consent at any time.
· Availability of follow-up treatment, care and support, and prevention services.
· Importance of disclosure, index and social network testing and availability of couples
HTS.
Age of Consent
The current guidance on the age of consent and procedures to have an HIV test is in accordance
with the Tanzania HIV and AIDS Prevention and Control Act (2008)19 and its regulations that
are under discussion for policy revision. The Act states that:
· Individuals above 18 years of age and those below 18 years but married, pregnant,
sexually active, or otherwise believed to be at risk for HIV infection, may give consent to
access HTS.
· A young person below 18 years of age who does not meet the criteria mentioned in the
preceding sentence should receive HTS after receiving consent from their parent or legal
guardian.
· All children or youth who receive HTS shall be supported to disclose their results to their
parents/guardians.
· For persons with auditory, visual or mental impairment and those who cannot write, a
thumb print should be obtained and be regarded as informed consent.
When Consent is not necessary
Consent shall not be required in the following specific situations:
·
·
·
·
2.3
When HIV testing is ordered by the court of law.
For human organs and tissue donations.
For sexual offenders.
Medical Practitioners may conduct HIV testing for patients without their consent if the
person is unconscious and unable to give consent and they reasonably believe that the
HIV test is clinically necessary or otherwise in the best interest of the patient.
Confidentiality
HIV Testing Services are confidential. The HTS provider shall not share any information
discussed with the client(s) or patient(s) with another person, unless the client(s) or patient(s)
give consent. Therefore:
19
The HIV and AIDS (Counselling, the Use of ARVs and Disclosure) Regulations, 2010
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· HTS providers must remain committed to preserving confidentiality on the test results
and any personal information, for example, information concerning their sexual behaviour
and the use of illegal drugs, and
· Avoid practices that can inadvertently reveal test results to others in the waiting room or
in the health facility.
· Health facility management should ensure that all HTS providers receive training regarding
the confidentiality of medical records.
Confidentiality among Couples/Sexual partners
With regards to HTS for couples and people in a sexual relationship, both partners should be
encouraged to keep one another’s HIV test results confidential until they decide together to
disclose their results to another person/s i.e. shared confidentiality between the HTS providers
and both partners.
Confidential Record Keeping
Confidentiality in HTS maintains the same underlying principles as confidentiality of other
medical information and records. It is meant to protect the dignity of clients and patients.
Health facility management and HTS providers shall ensure that: · All personnel with access to clients’ or patients’ medical records shall be trained in
procedures to maintain confidentiality.
· Clients’ and patients’ records shall be stored in lockable cabinets or rooms.
· Only staff with a direct role in the client’s or patient’s management, or specific data
management staff shall have access to these medical records.
Correct test results
All HTS providers should adhere to the national HIV testing algorithm and ensure provision
of high-quality testing services and correct diagnosis as outlined in Chapters Six and Seven.
Misdiagnosis of HIV status or presentation of HIV false positive results has been reported to
be occurring in some resource-limited settings, there is therefore need to provide the client
with correct test results.
2.5
Connection to services
The expansion of HTS must be supported by effective and efficient linkage to HIV prevention,
care, treatment and support services. It is the responsibility of all health facility
managers, HTS programmes and HTS providers to ensure that HTS clients and patients are
connected with appropriate follow-up services.
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CHAPTER THREE: HIV TESTING SERVICES (HTS) PACKAGE
Preamble
When a client/patient receives an HIV diagnosis it empowers them to make an informed
decision about HIV prevention, treatment, care and support services. The HTS package
recommended in Tanzania includes demand creation, pre-test information, HIV testing, posttest counselling, and successful linkages to prevention, treatment, care and support services
for both HIV positive and HIV negative individuals (Figure. 3.1).
Figure 3.1: HIV Testing Service Package
Create
Demand
For HIV
Testing &
Treatment
3.1
Deliver
Pre-test
Information
Perform
HIV Testing
using
National
algorithm
Deliver
Post -test
Counseling
Refer and link
• HIV POSITIVE: Immediately for
ART, Care and Support services
• HIV NEGATIVE:
Prevention and Support services
Promotion of HIV Testing Services
Promotional activities focus on informing communities/individuals about the availability
and benefits of HTS as well as sensitising, mobilizing and creating demand for HTS for
communities/individuals. These activities aim at increasing support and utilisation of HTS,
changing norms and reducing stigma. The information provided should be accurate and
relevant to the target population, culturally sensitive, and should reflect current evidence
and technological advances. The MOHCDGEC, Regional Medical Officers (RMOs) and
District Medical Officers (DMOs) shall be consulted to provide support for the development
of promotional materials and activities.
Some of the common examples of promotional activities include:
· Conducting Mass and Social Media campaigns,
· Development and distribution of information, education and communication (IEC)
materials, and targeted community mobilization,
· Posting signboards with information and messages on benefits of knowing your HIV
Status
· Provision of HTS as Combination Prevention interventions services package.
Mass and Social Media
Mass and social media are used to communicate messages about HIV testing and related
services to an entire population or to specific segments of the population. Therefore;
· Health Management and HTS providers may select the following channels for mass and
social media:
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· Billboards, television, radio, newspapers, road shows, and folk media
· Applications such as WhatsApp, Face Book and Twitter.
· The MOHCDGEC shall approve HTS related mass and social media messages.
Information, Education and Communication (IEC) Materials
High quality IEC materials are important elements of promotional activities for HTS.
Effective IEC can be achieved through: · Increasing awareness and creating demand for HTS and related services both at health
facility and community levels.
· Ensuring the availability of printed and/or electronic materials addressing all elements of
the HTS package at all HTS sites.
· Providing materials in Kiswahili and English with culturally appropriate illustrations and
graphics.
· Short video clips can be shown at the health facility and public places.
Advocacy, Sensitization and Mobilization
HTS providers shall:
· Engage community leaders, community HTS providers such as trained Community
Health Workers (CHW), Peer support groups and PLHIVs to provide information for the
promotion of HTS at public community functions or during interpersonal communication
with individuals, couples, and family members.
· Ensure that the information and messages shared with communities are accurate,
culturally sensitive and consistent.
· Collaborate with CHWs and PLHIVs who are effective in providing messages and reaching
specific populations.
Signboards
All facilities and sites providing HTS shall have signboards clearly marked that HTS are
offered with no fee. The signboard shall indicate the days and time when the services are
offered. Within the facilities, each HTS delivery point shall also be marked, e.g. on the
door, indicating that HTS are offered at that respective point.
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Combination Prevention Interventions
Another approach for providing information about HTS is through periodic campaigns. In
order for these campaigns to be most effective the organizers must:
· Have prior planning sessions with national/regional or districts officials to ensure
availability of adequate testing resources for the demand created.
· Ensure that the campaigns target specific populations or groups of people that may be at
an elevated or continued risk of contracting HIV.
· Continuously monitor the campaign theme to ensure that it remains relevant throughout
the duration of the campaign.
3.2
Creating an Enabling Environment
All HTS providers should be aware of critical enablers, i.e. elements outside the health
sector that facilitate the provision of effective and safe HIV Testing Services. Critical
enablers are key to the success of health sector HIV interventions. Examples of such
elements are: · Preventing violence: HTS providers shall set conducive environment that will protect
safety and privacy of clients/patients. This will ultimately help to minimize violence from
family members, employers and the larger population in relation to their HIV status.
· Flexibility for testing time: HTS should be provided during all hours that health facilities
provide other services including weekends and public holidays.
3.3
Pre-Test Sessions
Once a client(s) or patient(s) has/have completed registration they shall receive basic pretest information that will help them to understand the reasons for testing, HTS processes
and procedures, and the possible test results they may receive.
Pre-test information/counselling shall be provided to individuals, couples, families, or
groups. Couples shall be encouraged to receive pre and post-test counselling together.
When group pre-test information is provided, client(s) or patient(s) should still be given the
opportunity for an individual pre-test session with an HTS provider to address any personal
concerns or questions.
Ask if the Patient/Client is participating in the Vaccine Trail and its implication on the results
Additional counselling and condom demonstration should be conducted during the HIV test.
The sessions can be shortened through the use of multimedia channels as outlined in
section 3.3.1.
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Minimum standards for Pre-test Information for all populations
The aim of the pre-test session is to offer or recommend HIV testing to a client or a group
of clients. Therefore, the HTS provider shall provide clear and brief information including:
· Information on the different modes of HIV transmission
· The benefits of HIV testing
· The meaning of an HIV-positive and an HIV-negative test result
· Clear information on the services available in the case of an HIV-positive or negative test
result.
· Assurance that the test result and any information shared by the client is confidential.
· Information on the Client’s option to refuse to be tested and assurance that declining a
test shall not affect the client’s access to other services.
· Assessment of risk behaviours and appropriate counselling
· Discuss the importance of Index testing and Partner Notification Services
· Information on the risks associated with blood contact.
· Provide assurance to client participating in the HIV Vaccine Trail on vaccine induced seropositivity.
Special considerations for pregnant or postpartum women
Pre-test information or health education for pregnant women or women who may become
pregnant should include:
· The benefits of early HIV diagnosis for mothers and infants.
· The potential risks of transmitting HIV to the infant
· Measures that should be taken to reduce mother-to-child transmission if a pregnant
woman is diagnosed as HIV positive, including the immediate initiation of ART to benefit
the mother and prevent HIV transmission to the infant.
· The importance of testing their sexual partner and adopting safer sexual practices.
Special considerations for couples or sexual partners
Couples’ counselling and partner testing promote mutual disclosure of HIV status and
increase the adoption of prevention measures, especially in the case of discordant
couples. HTS providers should ensure that pre-test information session for couples: · Is offered together. If they refuse, then they should be provided pre-test counselling
individually.
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· Focuses on current generalised risk assessment rather than concentrating on past sexual
behaviour or risks.
·
3.4
Includes an explanation that disclosure of HIV status to another person/third party is
desirable but must be done with consent from both partners.
HIV Testing
After the pre-test session, HIV testing shall be conducted according to the National HIV Testing
Algorithm and Quality Assurance procedures outlined in chapters 6 and 7.
3.5
Post Test Counselling Session
All individuals who received an HIV test should be offered quality post-test counselling when
being given their HIV test results. Post-test counselling shall be client-centred and focus on
the specific risks and needs of the client or patient, based on their HIV test results, stated risk
behaviours, and prior knowledge about HIV/AIDS.
Post-test counselling may be delivered to individuals, couples or families, depending on what
they agreed to, during pre-testing counselling. However, couples shall be encouraged to
receive post-test counselling together, when possible, to encourage mutual disclosure and to
support couples’ communication.
Post-test counselling for clients who test HIV-Negative
Individuals whose HIV test results are negative should receive the following:
· An explanation of their test result.
· Information on HIV prevention.
· Demonstration on correct use of male and female condoms and an initial supply of the
same.
· Information on the importance of knowing the HIV status of their sexual partner(s) and on
the availability of partner and couples testing services.
· Screening for TB and referral for TB services as appropriate.
· Referral and linkage to relevant HIV prevention services such as VMMC, PEP, PrEP posttest clubs, STI services and OST clinics for PWIDs.
· Recommendation for retesting based on the client’s level of exposure and/or ongoing risk
of exposure as detailed in chapter Six, Table 6.1.
· Clients should be offered an opportunity to ask questions and receive correct information.
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Special considerations for adolescents who test HIV negative
Adolescents who test HIV negative need information and education about adapting safer
lifestyles including: · Stop sexual behaviours that increase the risk of contracting HIV infection.
· Safer sex practices and a demonstration on correct and consistent use of both male and
female condoms for the prevention of unwanted pregnancy, HIV and Sexual Transmitted
Infections/ Reproductive Tract Infections (STIs/RTIs).
· Repeat HIV testing after 4 weeks if they have new sexual partner(s).
· Accessing HIV prevention services such as Voluntary Medical Male Circumcision (VMMC)
and engaging in youth clubs.
Minimum standards for post-test counselling for individuals who test HIV positive
Post-test counselling for individuals who test HIV positive should focus on the needs of the
client and be delivered in a non-judgemental approach. The HTS provider should do the
following:
· Explain the test results and provide counselling on how to cope with emotions arising
from the result. Clients should be encouraged to ask questions.
· Discuss immediate concerns and help the client to decide who in their social network
may be available to provide immediate support.
· Provide clear information on ART and its benefits.
· Assess and provide counselling on risky behaviours and other diseases.
· Provide linkage to care and treatment centres and support to facilitate enrolment on ART
on the same-day.
· Where same day referral to a CTC is not feasible, arrange and ensure active follow-up and
referral to a CTC.
· Inform the HIV positive clients that they will be retested to verify their HIV diagnosis prior
to enrolling in care and/or starting ART.
· Provide information and demonstrate correct use of male or female condoms.
· Discuss the importance of disclosure of the HIV test result, its risks and benefits among
couples and partners. Assess the risk of intimate partner violence and discuss possible
steps to ensure safety of clients.
· Assess the risk of suicide, depression, and other mental health consequences following
a diagnosis of HIV-infection.
· Discuss information about sexual contacts, injecting drug users and children and other
family members, request for consent to contact these groups for HIV Testing Services.
· Screen for Tuberculosis (TB) using the national TB screening tool and refer suspects to
TB programme services. For all TB suspects, encourage screening of all family members.
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· Provide referrals to other services such as STI/RTIs, prophylaxis for opportunistic
infections, family planning, cervical cancer screening, Gender Based Violence (GBV) and
legal services as appropriate.
· Identify and refer clients who are also participating in HIV vaccine research back to
research sites or to public hospitals that can perform Polymerase Chain Reaction (PCR)
to rule out Vaccine Induced Sero-Positivity (VISP).
Post-test counselling for special populations
In addition to the general post-test counselling messages for all individuals, the following
specific groups require more specific messages and repeat post-test sessions.
Key populations
All trained HTS providers in all regions targeted for KVP interventions should receive refresher
training on the 2017 National Guidelines for KVPs. In addition to the minimum standards for
post-test counselling process listed in section 3.6 above, HTS providers should provide:
· Intensified post-test counselling combined with linkage to, follow-up support by
community based HTS provider and “peer” volunteers where available.
· Linkage to a peer counsellor who may help KVPs tested HIV-positive and lack social
networks and/or a supportive family, to cope with the diagnosis and support enrolment
in care and treatment.
Pregnant women
Post-test counselling for HIV-positive pregnant women, in addition to the standard messages
described above, should include the following:
· Access to HIV Prevention of Mother to Child Transmission services.
· Screening for TB, STIs, particularly for Syphilis and Cervical Cancer.
· Counselling on maternal nutrition, including the need to take iron, folic acid and malaria
prophylaxis, increase the variety and quantity of meals, and reduce workload especially
during the last three months of pregnancy.
· Childbirth plans: providers should encourage HIV-positive pregnant women to deliver in a
health facility for their own safety as well as the safe birth of the newborn.
· HIV testing for the infant and needed follow-up for HIV-exposed infant.
· Counselling on safer infant feeding practices to reduce the risk of HIV transmission during
the breastfeeding period:
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· HTS providers should give correct and up to date information on the different infant
feeding options with support to decide on their feeding choice.
· Where available, HIV positive mothers should be referred to an Infant and Young Child
Feeding (IYCF) trained provider.
Couples/sexual partners
Post-test counselling for couples/sexual partners requires enhanced counselling skills. Posttest counselling for sero-discordant couples may be especially challenging, as test results
may be hard for the provider to explain and difficult for the couple to accept. These guidelines
recommend that all HTS providers should receive additional training/refresher training using
the National Couple Counselling training materials of 2017.
Post-test counselling for HIV-exposed infants and children.
Informing children of their HIV diagnosis is complicated. The approach depends on the child’s
age and the counselling skills of the health–care provider. HTS providers should refer to
National Training guides and appropriate guidelines for details on how to do this.
Young Children (less than 10 years old)
· Disclosure of a young child’s HIV status shall be handled in an age appropriate manner. It
is a process that develops over time.
· Some young children may not understand that they are being tested for HIV, but if they
are positive, they will need to be made to understand the importance of taking their
medication and staying healthy.
· Some young children will understand that they are being tested for HIV, and HTC providers
shall be prepared to facilitate disclosure to children, if applicable.
· For young children who are able to comprehend, the HTS provider may participate in
the disclosure session, however, much of the information during the session should be
provided by the parent or guardian.
· Providers may wish to disclose a child’s results to the parent or guardian before disclosing
them to the child. This allows parents or guardians time to process the test results, initiate
discussion about follow-up care and treatment for the child, and decide the best time and
method for disclosure to the child.
· When deciding how and when to safely disclose, HTS providers and parents/guardians
shall consider the level of cognitive development and emotional maturity of the child, as
well as the child’s ability to handle difficult situations.
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· HTS providers and parents/ guardians should introduce age-appropriate information
regarding HIV as early as possible, be transparent and work on reducing potential HIV/
AIDS related stigma.
· It is recommended that full disclosure of a child’s HIV status takes place by the age of 10
years.
Adolescents (above 10 years and below 18 years)
Adolescents are generally capable of understanding the HIV test and test results, and the
HTS session will generally be directed at the older child and the parent(s) or guardian(s) if they
are present during the session. Along with standard messages for all those diagnosed with
HIV-infection, post-test counselling for adolescents whose test result is HIV-positive should
include:
· Provider-assisted disclosure of the child’s HIV test results to the parent or guardian
may help facilitate access to care and treatment, and may open lines of communication
between parents/guardians and their children.
· Adolescents are generally becoming (or are already) aware of their sexuality, and may have
special counselling needs around HIV and relationships, sexuality, and risk reduction, in
addition to care and treatment support.
· HTS providers shall also be aware of the differences in counselling and support needs
for these adolescents who have been living with HIV since birth, and those that became
infected in their youth.
· Educational messages and materials that address the prevention, care and treatment of
HIV shall be developed specifically for older children.
· Since adolescents might not want to receive services in the same place with adults
receiving HTS, “youth-friendly” HTS and providers shall be made available, and where
feasible, expanded to meet the needs of older children.
· Linkage to HIV care and treatment, specific psychosocial and mental health services
according to the situation in which infection happened and the developmental age of the
individual.
· An opportunity to ask questions and discuss issues related to sexuality and the challenges
they may encounter in relationships, marriage and childbearing.
· On-going counselling and in particular around the time of transition into adulthood.
· Referral for small group counselling and structured peer support groups.
· Information on their rights and responsibilities, especially their right to confidentiality.
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Vaccine Induced Sero-Positivity (VISP)
Vaccine-induced sero-positivity refers to a situation whereby serological tests detect vaccine
induced antibodies to client(s) participating in HIV vaccine research. VISP is a major focus
in the preventive HIV vaccine field because the most common tests for HIV infection rely on
detecting antibodies to HIV, they may also detect antibodies induced by the HIV vaccine.
Box 3.1 Vaccine Induced Sero-Positivity (VISP)
The associated VISP can be addressed as follows:
Research institutions conducting HIV vaccine trials must always conduct testing for VISP to
all study participants at the end of the study to prevent social harm, incorrect HIV diagnosis,
and inaccurate reporting to health care facilities.
· They should sensitize local government authorities and health care staff at all levels,
particularly in regions with ongoing and planned HIV vaccine trials.
· HTS providers can minimize misinterpretation of VISP by obtaining a complete client
history e.g. by asking if they are participating in an HIV vaccine trial.
· Clients should be asked if they have an HIV vaccine research identification card that
shows one is/was a participant. If needed, referrals for PCR can either be done by referring
clients back to the research site or to a public hospital capable of performing PCR.
3.6
Disclosure of HIV Status
Disclosure refers to when a person who has undergone an HIV test shares the test results with
other individuals. It also refers to the process of an HTS provider sharing a client’s or patient’s
HIV test results with the client or patient, or with a third party. Test results may be disclosed
to the individuals receiving HTS alone and/or to couples or families who agree to receive their
results together.
Maintaining privacy about HIV-positive test results is key to HTS, particular attention is needed
to protect client/patient safety and privacy.
3.7
Linkage to Care, Treatment and Support Services
HTS providers have a crucial responsibility to ensure that all individuals with a confirmed
reactive HIV test are immediately linked to care and treatment services for enrolment to ART
and other support services. Therefore:
· Every HTS site should map and keep a directory of all HIV and AIDS support services
in the catchment area. This should be done in collaboration with HTS, ART providers,
social workers, community development and other extension workers in the catchment
area (see Figure 3.1)
· HTS providers shall record referrals in the HIV testing register and fill the MOHCDGEC
approved referral form in duplicate (One form to take to the CTC and a copy to be
maintained at the testing site).
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· Where feasible, HTS providers shall arrange for escort/or verify by phone that all referred
individuals have been received at the CTC and enrolled into care and treatment
· ART providers shall re-test all the referred individuals to verify their HIV positive status
before they enrol them at the CTC. They should fill the referral form and send feedback
to the HTS provider.
Strategies for Effective Referral and Linkage
· Immediately refer or link all people who test HIV-positive to ART services.
· Refer all people who test positive in community settings to a health facility-based Care
and Treatment services for verification of HIV test results and further assessment for care
and treatment services.
· Link people who test HIV-negative with ongoing HIV risk to appropriate prevention
services.
Figure 3.1 Post Test Linkages to Treatment Care and
Figure 3.2: HIV Post-test LinkagesSupport
to Prevention,
Care and Treatment Services
Services
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CHAPTER FOUR: HTS DELIVERY APPROACHES AND SETTINGS
Preamble
The 2016 HIV Service Delivery Model Mapping Report revealed that there are many settings for
providing HTS in Tanzania. These guidelines recommend prioritization of a mix of approaches
and settings that will facilitate early HIV testing and diagnosis of many individuals, focusing on
populations with the highest risk for HIV as well as underserved geographic areas. They also
emphasize timely and effective linkage to prevention, care and treatment services. According
to these guidelines, all newly diagnosed HIV positive individuals shall be re-tested and verified
as HIV positive before they are enrolled into Antiretroviral Treatment. Those testing HIV
negative shall be asked about their sexual behaviour to identify HIV, linked to HIV prevention
services and provided with knowledge on when to re-test.
4.1
Approaches and Settings for HTS Delivery in Tanzania
The main approaches for HTS are Provider-Initiated HIV Testing and Counselling (PITC) and
Client-Initiated HIV Testing and Counselling (CITC) see Figure 4.1. HIV self-testing (HIVST) has
been recommended by WHO as an additional approach for delivering HIV testing services.
The introduction of HIVST will be based on the recommendations from the ongoing 2018
Implementation Science on HIVST. The HTS are delivered in two broad settings, namely
community and facility based settings.
4.1.1
Provider-Initiated HIV Testing and Counselling (PITC)
PITC refers to situations in which a health care worker or HTS provider recommends and
offers HTS to individuals, couples, families, or groups attending clinical services in health
facilities as a standard component of medical care. PITC may also be recommended in nonfacility settings i.e. in community settings.
· PITC providers shall give clients/patients basic pre-test information, in an individual,
couple, family, or group setting. Testing may be done by the provider in the consultation/
private room or in a designated side room by a designated HTS provider, or in the
laboratory. Results shall be given to the patients/clients, along with appropriate post-test
counselling and linkage to follow-up services.
· Given the high time demand in PITC settings, post-test counselling may be streamlined.
It is recommended that these patients/clients be referred to a counsellor or support group
for on-going counselling and support as needed.
· Patients/clients who decline PITC shall still be provided with high quality medical care for
their presenting illnesses.
· PITC services shall be expanded and integrated in all facility and community health
services provision points. Examples of these services are listed below.
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Figure 4.1: The main HTS approaches and settings
Reproductive Maternal, New-born, Child and Adolescent Health (RMNCAH)
It is now the standard policy in Tanzania to offer routine PITC as part of RMNCAH care
including Antenatal Clinics (ANC), Postnatal Care, Family Planning and couples’/partners
health services
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Child health services
All children below the age of 18 months admitted as paediatric inpatients, with or without signs
and symptoms of HIV infection, all HIV exposed children, and all children whose mothers’ HIV
status is not known shall be offered HIV testing with the consent of their parent(s) or guardians.
PITC shall also be offered in outpatient departments to all children accessing various RCH
services and specialized paediatric clinics.
Integrating HIV Testing with TB services
In Tanzania, TB/HIV co-infection is estimated to be 37-39%. Intensified TB case finding in
clinical and outreach settings will facilitate early detection of HIV-associated TB and linkage
to treatment and appreciably contribute to the reduction of morbidity and mortality associated
with TB. These guidelines emphasize that: · HTS providers shall integrate TB screening wherever HIV testing is carried out irrespective
of their test result.
· Health providers in TB settings shall ensure that all patients/clients diagnosed with TB
shall also receive HIV Testing Services (Index patients/partners).
Integrating HTS in STI services
Service delivery points for Sexually Transmitted Infections (STIs) are one of the key entry
points for HIV prevention, care, and treatment and support services. Therefore, all STI service
providers should:
· Provide HTS to all patients diagnosed with STI.
· Routinely offer STIs and HIV testing services to all pregnant women attending ANC.
Voluntary Medical Male Circumcision (VMMC) services
Voluntary medical male circumcision can reduce HIV acquisition in HIV negative males by
60%. The MoOHCDGEC has developed a strategy for providing VMMC services with HTS as
one of the VMMC packages. All health Workers and HTS providers shall ensure that:
· All persons receiving VMMC shall be offered HTS. However, HTS shall not be a precondition
to access VMMC services.
· Clients accessing HTS are informed about the benefits of (VMMC) for HIV prevention and
referred to VMMC sites.
4.1.2
Client-Initiated HIV Testing and Counselling (CITC)
Client-initiated HI V Testing and Counselling previously referred to as Voluntary Counselling
and Testing (VCT), is an approach in which client(s) voluntarily decide to learn their HIV status
as an individual, couple or family. CITC offers many opportunities for more personalized risk
assessment and client-centred behaviour change counselling.
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In Tanzania, CITC services are offered within health care facilities as well as in the community
as stand-alone sites, in outreach services, in homes or in workplaces.
Stand-alone CITC service delivery points
· Stand-alone CITC sites provide services to the general population, or can be tailored to
meet the needs of specific populations, such as persons with visual, auditory, and/or other
disabilities, youth, or KVPs.
· HTS providers in stand-alone VCT sites shall also integrate other health services in order to
maximize the benefits of these sites.
· Health managers should provide guidance on the planning and supervision of Mobile/
outreach services in order to ensure HTS providers sustain high-quality HTS services,
adhere to the 5Cs Core principles of HTS, infection control SOPs, and provide immediate
linkages to CTC services.
4.1.3
Community Based HIV Testing Services (CBHTS)
This refers to HTS offered to individuals, couples and families outside of health facilities. It is
an important approach to reach those who test HIV for the first-time and people who seldom
use clinical services.
Community based HTS can be provided in a variety of settings including: Home-Based HTS,
stand-alone community HIV testing services; and HIV self-testing.
Home-Based HTS (HBHTS)
In the HBHTS approach, an HTS provider may visit a household or be requested by clients/
patients to visit their home to offer HTS to individuals, couples, and families within the
household setting. HBHTS includes aspects of both PITC and CITC. One of the advantages
of this approach is that it builds upon the existing community health setting and facilitates
linkages with other health services. However, HTS providers need to receive additional training
for them to effectively offer HBHTS. There are two primary models for conducting homebased HTS in Tanzania: door-to-door and index-patient models.
Door-to-door HBHTS model
In this model, HTS providers aim to provide HTS in all homes within a specific, pre-defined
geographic area. This model requires strong community linkages and advance preparation to
ensure acceptance into the community and homes. The approach is best utilized in areas with
a high population density, low numbers of people previously tested, or high HIV prevalence.
4.1.4
Index client testing and partner notification model
· Index client HIV Testing is a focused HTS approach in which people diagnosed with HIV
are encouraged and supported to have their sexual partner/s, children, other household
and family members access HTS20. PWIDs should also be offered this service for their
networks.
20
World Health organization: Guidelines on HIV self-testing and partner notification: supplement to
consolidated guidelines on HIV testing services; 2016
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The following steps should be followed when implementing index client testing:
· HTS providers should counsel every client who test HIV positive on the importance of
ensuring their partner/s children and family members are also tested.
· With consent, the index client’s sexual partner/s and children may be referred for HTS
using the following approaches:
o
Passive disclosure approach whereby the index client discloses their status to their
sexual and/ or drug injecting partners by themselves (unassisted), and also suggests
HTS to their partner(s)
o
Assisted voluntary disclosure approaches whereby with the client’s consent, the
HTS provider anonymously notifies their sexual and/or drug injecting partner(s) using
three approaches:
i.
HTS provider contacts the index client’s partners directly and confidentially.
ii. The HIV-positive client enters into a contractual approach with the HTS provider
and agrees to disclose their HIV status by themselves and refer their partner(s)
for HTS within a specific time period e.g. one month. If the partner does not
access HTS or contact the provider within that period, the provider will contact
the partner(s) directly and offers voluntary HTS.
iii. HIV-positive client opts for community/home visit by the provider when they
disclose their HIV status to their partner(s). The HTS provider then offers HTS to
the sexual partner(s), children and other family members who agree to receive
HTS. This is also referred to as Dual approach.
These guidelines emphasize enhanced use of this approach throughout the country as among
the new innovations to rapidly increase the number of PLHIV diagnosed.
4.1.5
HTS approaches for KVPs
Approaches and delivery of HTS for KVPs in health facilities shall aim at locating KVP services
at friendly corners and friendly times to promote their confidentiality. In the community, efforts
should be made to access them in their natural environments such as “moonlight services”.
Suggested HTS sites for reaching key populations include:
· Needle and Syringe Programme (NSP) sites;
· Methadone Assisted Therapy (MAT) sites;
· Home-based HTS sites;
· Mobile or outreach HTS at hotspots e.g. bars, guest houses or brothels;
· Other closed settings such as prisons;
· As much as possible, referrals and linkages for additional services should address the
individual’s medical, psychological, social, vocational and legal challenges.
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4.2
Integrating Community –Based HTS
Health Managers and HTS providers should promote the integration of Community –Based
HTS with other community health services as outlined in the 2015 NACP’s National guidelines
for Community Based HIV and AIDS Services. Examples of services that can be integrated
with Community –Based HTS include: · Home-based HIV care, TB screening and treatment, EPI and child growth monitoring
and promotion programmes, Malaria screening, ANC services, family planning, cervical
cancer, and non-communicable diseases screening.
· Health education services, health campaigns during national events such as the
International Trade Fair - Saba Saba and the National Farmers’ Day Nane Nane, Village
Health Day, World AIDS Day, Uhuru Torch Race sports tournaments e.t.c)
Personnel Conducting Home/Community Based HTS
· Home/community based HTS providers must be certified by the MOHCDGEC.
· It is recommended that Home-based HTS Providers shall work in pairs and where
possible the pairs should comprise a male and a female. It shall also be useful to have a
community gatekeeper or mobilize to accompany the providers.
· Members of PLHIV Post-test clubs (PTCs) shall be oriented on how to effectively mobilize
communities and on the 5 Cs core principles of HTS.
· There shall also be an experienced team leader or senior counsellor available on-site or
in nearby facilities to provide professional backstopping to Home-based HTS providers.
Planning Home-Based HTS
· HTS providers must carry all necessary HTS supplies with them, and adhere to the
standards and quality assurance systems outlined in these guidelines and accompanying
Standard Operations Procedures.
· Home-based HTS also require advance preparation and engagement with local leaders
to gain access to the community and peoples’ homes.
· Providers should adhere to bio safety and waste precautions, appropriate lighting, allow
tests to develop for the appropriate amount of time, ensure appropriate temperature for
test kits and supplies, ensure confidentiality, and maintain high quality services.
4.3
HTS in Workplace Settings
HTS shall be offered in public and private sector work places as part of routine, comprehensive
workplace HIV programmes in line with HIV and AIDS (Prevention and Control) Act 2008.
· Workplace HTS may be provided on-site through a workplace clinic or in coordination
with a nearby HTS centre. HTS providers may visit the workplace and offer HTS, either in
an office room, a mobile van, or in tents. HTS may also be introduced into a workplace on
an ad hoc basis, for example during an annual family day or event.
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· A workplace HIV Focal person may offer information about HTS and refer employees to a
nearby HTS site to receive services.
· HTS providers shall provide sufficient information to employees to enable them make
informed decisions about HTS, and access them voluntarily; that is, workers or their
families shall not be forced to be tested by their employer.
· All personal data relating to an employee’s HIV status or other personal information shall
not be disclosed to the employer unless the employee provides written consent to do so.
· Employers should promote continual education of employees in relation to HIV and AIDS
preventive, care and treatment service as a method to minimize stigma and discrimination
related to HIV and AIDS.
· Workplace HTS providers must adhere to MOHCDGEC SOPs for HTS, paying particular
attention to waste disposal.
4.4
Health Care providers and Risk of exposure to HIV
All HTS management should incorporate the welfare of all staff involved in service delivery
by ensuring that: · All HTS providers are oriented on the national post exposure prophylaxis (PEP) guidelines.
· All HTS sites are equipped with PEP equipment and supplies at all times. Where not
available the staff shall be well informed of the next level to get them.
· Providers who are accidentally exposed to HIV through occupational exposure, shall
report the exposure to the employer as per national PEP Guidelines 2014.
4.5
HIV Self-Testing
HIV self-testing (HIVST) has been recommended by WHO as an additional approach for
delivering HIV testing services. The HIV self-testing (HIVST) approach is defined as the
process whereby an individual collects their own specimen (blood or oral fluid), performs
HIV testing using a HIV Rapid Diagnostic Test (RDT) and interprets the result themselves
either assisted or unassisted. The HIVST does not provide a definitive diagnosis. A reactive
(positive) result always requires further confirmatory testing from a trained HTS provider
using the relevant validated national HIV testing algorithm. The WHO strongly recommends
the introduction of HIV Self-Testing (HIVST) as one of the approaches for rapidly increasing
the number of new testers. The process of adapting HIVST has commenced and operational
studies that will better guide the adaption of HIVST in the country are currently underway.
4.6
Other HIV Testing Approaches
Other HTS approaches include mandatory testing, testing of blood and tissue donations, and
testing for the purposes of research or surveillance. These approaches are further described
below:
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CHAPTER FIVE: PRIORITY POPULATIONS
Preamble
HIV Testing services should be made available to individuals, couples/partners, families and
KVPs. It is a fundamental human right for all Tanzanians to know their HIV status. This chapter
outlines key considerations for different populations.
5.1
Key and Vulnerable Populations
Key and Vulnerable Populations are persons who engage in socially stigmatized behaviours
including sex work, injecting drug use and male-to-male sexual relations. HIV may spread
rapidly in these populations due to more frequent exposures in high risk behaviours such as
unprotected anal and vaginal sex with partners of unknown HIV-status and the sharing of
syringes and needles. The risk of HIV infection among these groups multiply because persons
who engage in these behaviours often overlap (e.g. sex workers who inject drugs, men who
have sex with men who engaging in commercial sex, a female injecting drug user engaging in
receptive anal sex). In addition, since these populations are mostly hidden due to our cultural
context, they are harder to reach, and less likely to have access to services, or to use services
where they are available.
Therefore:
· Priority interventions and enabling environment should be in place to ensure that KVP
receive HTS without stigma or discrimination.
· Community based HTS targeted for KVP is a recommended approach for reaching more
KVPs.
· HCWs should receive training on provision of KVP-friendly services based on the current
KVP guideline.
· Community based health care providers and peer educators should be used to sensitize
and mobilize KVPs to seek HTS.
5.2
Infants and Children
Mortality rates among infants infected with HIV who go untreated is very high in the first year
of life. All babies and infants known to be HIV exposed should be tested for HIV at the age
of 6 weeks. HTS for older children should be age-appropriate. Providers should make an
assessment of level of maturity in a particular age. Approaches for delivering age-specific HTS
for children are elaborated in Chapter Six.
5.3
Adolescents
Health management officials and HTS providers should ensure adolescent-friendly services
are strengthened and/or established either as adolescent-friendly corners or provided on
special days and times.
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Groups of adolescents who need special considerations are:
· Adolescents infected vertically who were not diagnosed in infancy.
· Adolescents acquiring HIV horizontally through early sex and injecting drugs.
· Adolescents from key populations.
· Vulnerable adolescents such as those living on the streets, orphans and adolescents in
child-headed households.
· Girls in-school and out-of-school aged between 15 -19 years.
5.4
HTS for Orphans and Vulnerable Children (OVC)
Orphans and Vulnerable Children shall have access to health care services including HTS, and
shall receive appropriate treatment, care and support, based on their HIV status. There are
some unique situations that may need to be considered by HTS providers and guardians who
serve OVCs, including:
· OVCs should not be forced to take an HIV test, but shall be supported to do so when it is
in their best interest, i.e. for their own health and well-being.
· Health care providers shall discuss with parents/guardians on how to talk to OVCs in an
age-appropriate manner about the risk of HIV infection and the benefits of treatment, care
and support.
· In collaboration with social welfare and community development service providers, HTS
providers shall address the risks and needs of children and youth living in the streets,
and support them to develop risk reduction plans, and link them to appropriate follow-up
services.
5.5
Pregnant Women
HIV testing in Ante-Natal Clinics (ANC) settings has considerable public health benefits in
reducing and eventually eliminating the transmission of the HIV virus from mothers to their
children. Currently HTS is offered in all ANCs as per National policies.
5.6
Men
Currently fewer men than women report ever testing for HIV. Men are more likely to start
ART at later stages of HIV infection and thus experience higher morbidity and mortality after
initiating treatment.
It is therefore recommended that Health managers and HTS providers: · Promote male involvement in health care services such ANC, PNC, FP, RCH.
· Integrate HTS with men-targeted services such as VMMC and other mobile, home-based,
or workplace health services at all levels.
· Implement defined combination prevention interventions targeting men.
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5.7
Couples and Partners
In order to facilitate disclosure, identify discordance, and prevent HIV transmission between
couples/partners, HTS managers should strengthen the following: · Training/refresher training of HTS providers on Couples HTS delivery.
· Provision of Health information to raise awareness on the importance of HIV Testing
services among individuals engaged in sexual relationships.
· Promotion of a conducive environment for Couple HTS such as allocating afternoon times
for couple HTS, and/or using events such as Valentine’s or Christmas months to offer
couple HTS.
· Training/orientation of all HTS providers on how to screen clients for intimate partner
violence and provide appropriate support and referral to follow-up services.
· Where the HTS provider has reason to believe that one partner may have been coerced to
attend couples HTS or that there may be underlying partner violence; the provider should
separate the couples and recommend individual HTS first.
Discordant couples
There is a high risk of HIV transmission among HIV discordant couples. Health management
and HTS providers shall emphasize follow-up counselling and linking of discordant couples
with other supportive services including:
· Reproductive and Child Health Services including family planning and provision of
contraceptives.
· Offering PrEP services to all HIV negative sero- discordant couples.
· Providing PMTCT services for HIV-infected pregnant women.
· Voluntary medical male circumcision for male partners.
· Demonstration of correct use of condoms and explanation of where to access condoms
as needed.
5.8
Other Populations at Higher Risk of HIV Infection
In addition to key populations, there are other populations that may also be vulnerable to HIV
infection or may have difficulty accessing equitable health care services, including HTS.
Populations in Closed Settings
Prisoners and other persons in closed settings may either enter the prison with unknown
HIV infection, or may acquire HIV infection through high-risk behaviours while in prison. It is
recommended that Health management, HTS supervisors in collaboration with prisons health
authorities: · Sensitize the Prison Department and jail wardens to ensure that they establish
comprehensive HIV programmes including HIV prevention, HTS, care, treatment and
support services in prisons.
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· Offer PITC voluntarily to all prisoners at entry as part of medical screening and thereafter,
as needed e.g. when a prisoner shows signs or symptoms of underlying HIV infection.
·
Ensure that Post Exposure Prophylaxis (PEP) is provided following rape in prisons or
work place HIV exposure according to the national PEP protocol.
Uniformed Forces
Members of uniformed forces may be at a particularly high risk of getting HIV infection due
to long periods of time spent away from their homes or spouses, at times in other countries.
Therefore, military health authorities should:
·
Establish and promote HTS in all health facilities providing services to uniformed
personnel, their partners and children.
· Provide/solicit outreach and mobile HTS from public health facilities where stand-alone
services are unavailable.
· Integrate Voluntary Medical Male Circumcision (VMMC) with HTS.
· Effectively link members of uniformed forces to appropriate care, treatment and support
services after HIV testing.
Persons Abusing Alcohol and Other Drugs
Persons who abuse alcohol or other drugs may participate in high HIV risk behaviour due to
lowered inhibitions as a result of alcohol or drug use. Persons who are under the influence of
alcohol or other drugs at the time they present for HTS shall be requested to return when they
are sober.
Mobile populations and individuals employed in environments with high HIV risk.
Long distance drivers, bus drivers, mine workers, fishermen, plantation workers, frequent
travellers, road construction workers, taxi drivers, motorcycle and tricycle drivers may be at
an increased risk of HIV infection due to engagement in risky behaviours and long periods of
time spent away from home/family. Therefore: · Employers/self-employment unions should be capacitated with HTS promotion messages
and knowledge on basic HIV prevention services in their institutions, including condom
distribution.
· HTS providers should initiate/ strengthen interventions targeting these groups and should
include their sexual partners.
Refugees, displaced persons and migrants
Refugees, displaced persons and migrants may be vulnerable to HIV infection because they
are separated from family members or loved ones. They may also have language barriers that
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limit their ability to communicate with health care providers. Therefore:
· Health management shall ensure that refugees have access to comprehensive health
care services, including HTS and follow-up HIV prevention, treatment, care and support
services.
· HTS shall be provided through: health facilities, mobile/outreach or home-based
approaches.
· Institutions serving these populations may need to train additional providers who speak
the language of the particular population or hire interpreters/translators.
Survivors of sexual violence
Sexual violence is linked to the risk of HIV infection. Therefore:
· Health facility managers and HTS providers shall provide urgent HTS to survivors of
sexual violence including clinical evaluation, documentation, treatment and psychosocial
counselling.
· The management of all health facilities should ensure that PEP is available and accessible
at all times it is needed. Survivors should start PEP within 72 hours from the time of sexual
assault as per national PEP guidelines
· HIV testing should include syphilis screening and treatment, pregnancy testing and
emergency contraception where appropriate.
· In addition to PEP, sexually abused children should be referred to proper social welfare
services, and to medical and legal aid support as necessary.
· If sexual violence is committed by a parent or a guardian against their children, it is
recommended that the child should receive HIV test without the consent of their parents/
guardians and be given age-appropriate counselling.
Persons with Disabilities (PWD)
Persons with disabilities include anyone with physical, sensory (hearing, seeing) or mental
limitations. PWDs are vulnerable to HIV infection not only because of their clinical condition,
but also because they may not have equitable access to information, education and other
public services due to communication, attitudinal and infrastructural barriers. These guidelines
recommend the following:
· Health management and HTS providers shall make provisions to address barriers for
PWDs to access HTS in a manner that meets their specific needs.
· HTS providers may be required to attend clients or patients in their homes or other
appropriate settings.
· HTS service providers shall assess the client and their ability to comprehend the testing
process, give informed consent and understand their test results.
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CHAPTER SIX: HIV TESTING STRATEGIES FOR DIAGNOSIS
Preamble
The MOHCDGEC uses Rapid Diagnostic Tests (RDTs) for scaling up HIV testing. RDTs are a
critical tool as they can be used at any level of the health-care system, and a diagnosis can be
made for many individuals on the same day. They can be performed by HTS trained healthcare workers and laboratory professionals in various settings, irrespective of the infrastructure,
as they do not require specialized equipment. However, ongoing monitoring of correct HIV
test procedures and performance of HIV tests is required, especially when performed by nonlaboratory personnel and in hot and humid areas.
6.1
1.
2.
3.
4.
5.
Indications for HIV Testing
Knowledge of one’s HIV status.
Diagnosis of HIV infection in all age groups.
Screening of donated blood and blood products for transfusion.
Surveillance of HIV prevalence in a given population.
Management of sexual assault cases.
6. Management of work-related exposure to HIV.
6.2
Testing Strategy for Diagnosis of HIV in Adults and Children Aged 18 Months or
Older
In adults and children 18 months or older, HIV diagnosis should be done by detecting antibodies
to the HIV virus using rapid HIV tests. Rapid tests can be performed using whole blood, serum
or plasma samples. In Tanzania, finger-prick whole blood samples are used for HIV rapid
testing. The MOHCDGEC through the NHLQATC periodically reviews the different samples
or tests to be used for HIV testing based on prevailing scientific evidence. These guidelines
recommend a serial tests strategy using two approved samples. All qualified laboratory
personnel or trained HTS providers involved in sample collection, testing and reporting results
must adhere to this testing strategy.
The HIV serial (two) tests strategy shown in Figure 6.1 describes the following sequence of
samples and number of tests to be performed: 1. All samples should first be tested with one Test (T1), and samples that are non-reactive
should be reported HIV-negative.
2. T1 should be the most sensitive HIV test available, taking into account diagnostic
sensitivity, sero-conversion sensitivity and analytical sensitivity.
3. Samples that are reactive on the first-line test (T1 positive) should be tested with a
separate and distinct second test (T2) comprised of a different antigen preparation to
avoid false cross-reactivity with T1.
4. For samples that are reactive on the first-line test but non-reactive on the second-line
test (T1 positive; T2 negative), testing should be repeated using the same sample with
the same two tests.
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5. When the two samples use finger-prick whole blood, a new sample should be taken for
the repeat testing.
6. Samples that remain reactive on the first test but non-reactive on the second test (T
positive; T2 negative) should be reported HIV-inconclusive and the patient or client
should be asked to return for retesting in 14 days.
7. If after 14 days the test is still in determinant, it should be reported as inconclusive.
Fresh venous blood samples should be collected or the client/patient should be referred
to a higher level laboratory for PCR testing.
Figure 6.1: The sequence of blood tests in the Serial HIV testing strategy
Note: For clients who are participants of experimental HIV vaccines trials
collect venous blood sample and send to PCR Laboratories
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Diagnosis of HIV infection in breastfeeding children <18 months where the mother is known
to be HIV positive
If the mother is HIV positive, testing of the HIV exposed infant or child < 18 months should
follow these steps for diagnosis of HIV infection:
· Take a blood sample and do DNA-PCR from 6 weeks of age; if positive, start ART
immediately while waiting for second HIV DNA-PCR results.
· All children with HIV negative results should have a final rapid test at 18 months to confirm
their status. Note: Final rapid test must be taken 3 months after complete cessation of
breastfeeding.
· If the child is being breastfed by an HIV infected mother, a negative antibody test does
not exclude an HIV infection. On-going exposure to HIV through breastfeeding continues
to put the child at risk of acquiring an HIV infection.
· A single positive DNA-PCR test means that the infant is presumably infected and should
be initiated on ART. A second DNA PCR sample should be taken immediately after
receiving positive test results so as to confirm the first test result. NB: The second test
should not delay ART initiation.
· For a child that was never breastfed: a single negative DNA PCR test after the age of 6
weeks excludes HIV infection.
· For a child that has completely stopped breastfeeding for more than 6 weeks prior to
virologic DNA PCR testing, a negative DNA PCR test excludes HIV infection.
· Children between the age of 9 and 18 months or after cessation of breastfeeding should
have a rapid HIV antibody test since maternal HIV antibodies started to diminish rapidly
between 9-18 months of age (Figure6.2).
FOR HIGH RISK INFANTS
A High risk child is one who is symptomatic, fulfilling WHO stage 3 or 4 criteria and a
DNA PCR test is not available but HIV antibodies are present (rapid test is positive), a
presumptive diagnosis should be made and ART started.
Diagnosis of HIV infection in Children <18 Months where the Mother’s HIV Status is Unknown
Testing of a mother is the best way to ascertain HIV exposure status of her infant. If the mother
is HIV positive, testing of the infant should follow the steps for diagnosis of HIV infection in
the HIV exposed infant or child < 18 months. If the mother is not available, test the child for
HIV infection using both antibody test. If the test result is positive, use DNA-PCR to confirm
the HIV infection.
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Diagnosis of HIV Infection in Children <18 Months where the mother is not available
Since the mother’s HIV status is unknown, the HIV exposure status of the baby needs to be
established. If the mother is not available, the guardian/ care taker should be counselled for
HIV testing of the child. Steps for Diagnosis of HIV Infection in a child where mother is not
available:
i.
Do rapid HIV antibody tests immediately the child is seen at the HF to determine HIV
exposure.
ii. If HIV antibody test result is positive and the child’s age is <18 Months: do HIV DNAPCR.
iii. If HIV antibody test result is positive and the child’ age is unknown: do DNA PCR
immediately. If the result is negative, repeat DNA-PCR after 6 weeks to confirm.
iv. If rapid HIV antibody test is positive and the child has stage Three or Four symptoms
(Presumptive Diagnosis), do DNA PCR test and start ART immediately.
v. If child is younger than 18 months and is symptomatic, HIV DNA PCR should be taken
even if the rapid antibody test is negative.
vi. All children with negative results should have a final rapid test at 18 months to confirm
their status.
Note: HIV exposed children should be seen monthly for the first year of life and should be
followed up as per recommendations for all children.
6.6
Managing and documenting HIV Test Results
Key information should be collected for each HTS encounter in all approaches and settings.
This data will allow the health provider to monitor service delivery in a standardised manner
and allow for useful analysis of data. Correct completion of standard data collection tools
should be done immediately after completing the test procedure for each individual/couple
as a key best practice for quality performance monitoring of HTS service delivery. Using the
above serial testing algorithm, the reporting of HIV diagnosis shall be as follows:
HIV negative results
· All samples are first tested with sample T1 (screening test), and samples that are nonreactive are considered HIV-negative and reported as such.
HIV positive results
· Any samples that are reactive on T1 shall be tested again using a different sample T2
(confirmatory test). For samples that are reactive on the first and the second sample (T1
and T2), the result should be reported as HIV-positive and the patient or client should
receive post-test counselling and immediate referral for ART.
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HIV inconclusive results
If the first and the second samples (T1 and T2), test results are not the same (indeterminate
results) the following should be done: · Repeat the full serial testing procedure (sample T1 and T2) immediately with a new sample
and where feasible by a different HTS trained health worker.
· If the two tests remain indeterminate, this should be considered an inconclusive HIV
result. The client or patient should be advised to return for re-testing after two weeks (14
days).
· If the client or patient still has inconclusive HIV test results after 14 days, blood sample
should be collected using DBS and sent to the NHLQATC for further testing.
· If the facility cannot take a DBS sample; then client should be referred to a higher level
health facility. A tracking plan must be made including his/her telephone number.
6.7
Retesting
Re-testing refers to additional testing of an individual after a defined period of time, using the
same testing algorithm on a second sample.
6.8
Retesting to validate HIV-seropositive status prior to ART initiation
· To ensure that individuals are not needlessly placed on life-long ART (with potential sideeffects, waste of resources, and the psychological impact of misdiagnosis), the NEW
RECOMMENDATION stressed in these 2017 HTS guidelines is to retest every new
individual diagnosed as HIV positive to verify their HIV status prior to enrolling in care and
starting ART.
· Retesting according to this procedure aims to rule out possible technical or clerical errors,
including sample mix-up through mislabelling and transcription errors, or errors from the
test device.
· The retesting should be conducted by a different provider using the same testing
algorithm. However, when there is only one health worker in the facility, s/he should be
the one do the repeat test.
· Retesting should preferably be conducted at the site where the decision about ART
initiation is made.
· If the HIV status is the same upon retesting, the individual’s HIV-positive status should be
considered as verified.
· If the test status is not the same upon retesting, the individual or their sample should be
referred for additional testing at nearby higher level facility testing site.
NOTE: All the time the Health Care provider in the testing site and ART site should be
accountable for Tracking and Linkage until the discrepancy is resolved.
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Critical Message to remember:
Individuals undergoing HIV testing must be made aware of the risk of incorrect diagnosis
if they do not disclose that they are on ART or had previously been on ART. ART may
suppress antibody production and lead to ‘’false –negative’’ results.
Figure 6.2: HIV testing Algorithm for Infants and young children
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6.9
Infection Prevention & Control and Waste Management
The occupational safety and health procedures as outlined in the National Guidelines for
Infection, Prevention and Control shall be adhered to by all HTS providers. The following
actions are important: · Sharps shall be disposed of in designated sharps containers
· Used test kits and other contaminated waste shall be placed in separate closed containers
according to National Waste Management Guidelines
· All medical wastes shall be properly incinerated, or disposed according to the National
Waste Management and Infection Prevention and Control (IPC) Guidelines.
· HTS providers, community and laboratory staff involved in handling and disposing
hazardous waste shall be adequately trained on biosafety and infection prevention and
control procedures.
· Workplace managers shall provide Personal Protective Equipment (PPE) to HTS providers
· HTS providers must regard all blood and body fluids samples potentially infectious and
shall take all standard precautions to protect themselves and their clients [HIV and AIDS
(Prevention and Control) Act 2008]
Table 6.1: Retesting Messages for individuals who test HIV Negative
Scenario
When to repeat HIV test
When to do future HIV tests
No “window” period
retesting
Re-test annually
A GENERAL POPULATION
General Population who
test HIV Negative with no
ongoing risk.
Inconclusive (Indetermi- Immediately repeat HIV
nate test results) HIV status test following the national
If still in inconclusive retest in 2
weeks. If still inconclusive take
the sample for PCR or refer the
client to a higher level facility/
laboratory
Have a spouse or partner
who is HIV Negative
(discordant couples)
4 weeks
Every 3 months until the HIV
positive partner has confirmed
viral suppression i.e. Viral Load
less than 1000 copies/millilitre.
Thereafter re-testing every 6
months.
Individuals on PrEP
4 weeks
Every 3 months
Individuals on PEP
4 weeks
At 3 and 6 months, then annually
HIV testing algorithm OR
repeat test by another
tester or laboratory
technician
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Have specific incident
of HIV exposure past 3
months
4 weeks
With each new known exposure
and if still negative, as for
general population i.e. annually.
Have an ongoing risk
of HIV infection (SW,
IDU,MSM)
4 weeks
Annually
Has STIs/ RTIs
4 weeks
With each new STI, if still HIV
Negative test annually
Survival of sexual violence 4weeks
or rape or experience
occupational exposure
As per PEP guidelines
Adolescents and young
people
Annually if sexually active
4 weeks
B: PMTCT SETTINGS
Pregnant women and
Third trimester, or during
partners counselled and
labour/delivery
tested during first ANC visit
Pregnant women who
had specific sexual risk
behaviour in past 3
months
Breastfeeding women
Six months after delivery, if still
negative test annually and with
each new pregnancy
· 4 weeks then
Six months after delivery.If still
negative test annually and with
· Third trimester, or
during labour/delivery each new pregnancy
6 months after last test
who were tested during
pregnancy, labour/delivery
If still negative test annually and
with each new pregnancy
Breastfeeding women with 6months;
unknown HIV status: test at
first postnatal contact
If still negative test annually and
with each new pregnancy
HIV Exposed infants
PCR test at 6 weeks after
birth.
Conduct Rapid antibody testing
at 18 months for confirmation
of HIV status. Repeat testing six
weeks after cessation of breast
feeding.
*High risk HIV exposed
infants
DNA –PCR at birth, then
at 6 weeks of age;
6 weeks after cessation
of breast feeding and a
confirmatory antibody (Ab) at
18 months
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CHAPTER SEVEN: QUALITY ASSURANCE AND QUALITY
IMPROVEMENT OF HTS
Preamble
Quality Assurance (QA) and Quality Improvement (QI) are essential components of all HIV
Testing Services. These measures help to ensure that HTS conform to set requirements
and standards. HTS coordinators and health care providers must have a systematic and
planned approach to monitor and assess the quality of HIV testing services on a continuous
basis. They shall also seek to consistently modify programmes in a way that improves the
effectiveness and quality of all HTS offered. More details on QA and QI can be found in the
National Guidelines for Quality Improvement of HIV and AIDS services (2017) and National
Laboratory Quality Assurance Framework (2016).
7.1
The Role of the NHLQATC in HTS
The National Health Laboratory Quality Assurance and Training Centre (NHLQATC), has the
mandate to plan and implement QA activities in order to monitor and improve the quality of
HIV testing. These activities include; production of proficiency testing (PT) panels, promoting
the use of standardized testing and QA register, HIV register (Rejesta ya upimaji wa VVU na
uhakiki wa ubora), or implementing external quality assessment (EQA)/PT schemes, analysis
of EQA data, and implementation of corrective actions.
The role of laboratory personnel at the health facilities.
· Ensure QA of HIV testing.
· Ensure that all testing SOPs are in place and adhered to.
· Ensure participation in EQA/PT schemes.
· Observe proficiency testing to ensure adherence to SOPs.
· Conduct training and mentorship for HTS providers on quality testing.
· Conduct supportive supervision to all HTS providers and testing sites.
· Perform QA audits and ensure corrective actions are done after PT.
· Ensure timely and accurate projection and accountability for HTS commodities (RDTs,
DBS and PT panels).
· Ensure proper storage and management of testing commodities in accordance with the
SOPs.
· Prepare reports on all HTS QA activities.
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7.2
Quality Assurance for HIV Testing Services
Quality Assurance is defined as the overall systematic processes and procedures to ensure
accurate and reliable HIV test results. Errors can occur at each step of the testing process
therefore measures must be in place to assure the quality of HIV testing. Systems for IQC,
EQA and Continuous Quality Improvement (CQI) must be in place at all HIV testing sites.
In order to ensure accuracy and reliability of HIV test results, health management and HTS
providers must ensure that the following basic QA components are established and/or
strengthened:
· All HTS providers conducting HIV testing should participate in HIV EQA schemes
· All persons performing HIV rapid tests must complete the national rapid test training,
including a practical component and competency assessment, and awarded a certificate
of competence. A copy of their certificate shall be made available at the HIV testing site.
The Health Laboratory Practitioner’s Council (HLPC) shall provide licenses to all successful
testers in accordance with the Health Laboratory Practitioners Act, 200721
· SOPs and visual aids for HIV testing must be available onsite and adhered to by all HTS
providers.
· There should be a continuous supply of appropriate HIV testing commodities.
· All persons performing HIV rapid testing must validate every new batch of test kit and
document it in the national HIV register before using it for HIV testing.
· All persons performing HIV rapid testing must follow the HIV Testing Algorithm and
document all HIV testing results in the National HIV register.
· HTS site supervisors, HTS focal persons, and/or authorised laboratory supervisors must
conduct quarterly supervision. They must also conduct competence assessment of HIV
testers, identify gaps and take corrective measures for quality improvement.
· HTS providers shall follow standard safety precautions as outlined in the respective SOPs
on safety issues, including personal safety and waste management.
· The immediate supervising laboratory (i.e. the laboratory with the capacity to provide
reference value or address challenges relating to HIV rapid testing) shall be responsible
for QA backstopping and CQI.
· Site in-charges shall ensure that HTS providers at HIV testing sites record HIV testing
data accurately and timely to ensure high quality data management.
7.3
Quality Control (QC)
· Quality control refers to processes and activities that ensure that testing procedures
are performed correctly, that environmental conditions are suitable, and that the sample
works correctly as expected. The QC process helps to detect, evaluate and correct errors
before test results are reported. It is a multi-step process with checkpoints throughout
the testing process.
21
URT, MOH, Health Laboratory Practitioners Act ,2007
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Internal Quality Control (IQC)
· Each HIV testing site shall perform IQC using known HIV-positive and negative samples
according to SOPs to ensure the production of accurate test results. If known positive
and negative controls are supplied by the manufacturer, these shall be run according
to the manufacturer’s instructions and SOPs. HIV rapid testers shall make sure that the
inbuilt control line in the test device is reactive before giving test results to a client/patient.
· Laboratory personnel shall provide IQC samples and it is recommended that HTS
providers run controls:
· At the beginning of each day, for high-volume sites which are defined as HIV testing sites
with 25 or more HIV tests performed in one day.
· Once a week, for low volume sites which are defined as HIV testing sites with less than
25 HIV tests performed in one day.
· Every time a new batch of HIV test kit is opened and recorded in the laboratory HIV
register and when an HIV test kit is exposed to potentially damaging conditions such as
extreme heat or sunlight.
· Every time when a new HIV tester starts working at a site.
External Quality Assessment (EQA)
External quality assessment ensures that tests are performed accurately, results are
reproducible, and errors are detected and corrected to avoid misclassification or incorrect
diagnosis. The EQA process helps to evaluate testing competence and reliability of HIV testing
procedures, assess performance of specific testing testers, establish the accuracy of reports
of HIV status, and provide information for self-evaluation.
Proficiency Testing (PT)
Participation of HIV testers in PT at least once in every year is one of the criteria to assess
their competency. All HIV Testing sites shall receive their proficiency testing results through
the NHLQATC within one month, and facilities that do not achieve level four of competency
assessment shall continue to receive technical support from the laboratories at each level of
the national laboratory system. The NHLQATC shall coordinate training on PT and register
and provide PT panels to all HIV testing sites. All testers shall perform HIV testing on the PT
samples on a rotational basis, and document the test results on a standard form. Testers shall
return the PT results to NHLQATC within the allocated time. The NHLQATC shall crosscheck
the results for accuracy. Any errors or mistakes shall be reported back to the site for corrective
action. Any PT results received from the PT service provider MUST be reviewed and the
reviewed records maintained at the testing site.
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Supportive supervision, site assessment and observed practice
· In regions and districts, HTS supervisors and/or staff from the referral laboratory supporting
the site shall conduct regular (at least once every quarter) monitoring and assessment of
each HTS site.
· All supervisors shall be trained on supportive supervision using the approved national
curricular and they shall use a standard checklist.
· The national supervisory team comprising of members from the MOHCDGEC and
laboratory regulatory authorities shall conduct supportive supervision including site
assessments and observed practice at the regional level.
· Any recommended corrective actions from a site/supervisory visit shall be implemented
before the next visit.
National HIV Testing Register (Rejesta ya upimaji VVU, Uhakiki ubora na matumizi ya
vitendanishi)
The HIV testing register is a critical tool for quality HTS services. It shall be used to ensure the
following:
· Recording of specific HIV test results for each test performed.
· Monitoring of the batch number, type and number of HIV test kit used, date of test run,
and name of the tester and QC results.
· Facilitate testers to address test kit problems, such as expired test kits or inconclusive
results.
Therefore:
· All testers shall fill in the HIV register immediately after conducting the HIV rapid test on
a client or PT sample(s).
· Authorised laboratory officers, HTS focal persons and site supervisors shall review the
HIV registers regularly for compliance.
7.4
Regulation on HIV Diagnostics
The quality of HIV test kits must be assured before and after they are in the market. The WHO
Pre-qualification of in vitro diagnostics promotes and facilitates access to safe, appropriate
and affordable diagnostics of good quality. WHO reviews the quality, safety and performance
of diagnostics that are available in the market in resource-limited settings; therefore:
· The MOHCDGEC has been using and shall continue to use WHO prequalified HIV rapid
test kits.
· The NHLQATC shall continuously monitor the quality, safety and performance of HIV test
kits used in the country.
· All rapid test kits utilized at testing sites must be subjected to both pre- and post-market
surveillance. The NHLQATC shall conduct in-country lot verification testing both before
and after distribution of test kits to testing sites to identify problems, if any.
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7.5
Site Audit, Certification, Accreditation and De-certification
Site Audit
· Regional and District Health Management Teams shall assess and certify all HIV testing
sites based on national set standards prior to the provision of services to ensure the
preparedness and credibility of the site to deliver quality HTS.
· A standard checklist (Stepwise Process for Improving the Quality of HIV Rapid Testing
(SPI-RT) checklist shall be used to ensure that the testing site has the set standards in
place. This is a prerequisite for certification by the MOHCDGEC. Site audits shall be done
biannually.
Site Accreditation
Sites that achieve a low score in one or more items in the checklist will be provided additional
support by the facility management team to improve the score and staging of levels (levels 0
to 4). Only testing sites that have achieved Level 4 will be accredited by an independent site
accrediting body appointed by the MOHCDGEC- Quality Assurance Department. Accreditation
shall be valid for two years.
Certification of HIV Rapid Testing Personnel
The Health Laboratory Practitioner’s Council (HLPC) shall provide a license and/or provisional
license to all successful testers in accordance with the set criteria.
All providers performing HIV rapid testing shall be ethically responsible for taking part in QA
measures by:
· Registering/retaining registration for a license to practice as per of HLPC Act 22, of 2007.
The certifying board shall provide a unique registration number that will be valid for two
calendar years.
· Participating in established EQA programs at least once in every two years.
· Attending refresher training related to HIV testing at least once a year.
· Demonstrating consistent competency in the HIV tests they perform.
· Performing quality, accurate and reliable testing, following testing and documentation
SOPs and documenting HIV test results as per standardized HIV register and instructions
(“ Rejesta ya matumizi na uhakiki ubora wa upimaji VVU”( 2017))
· Performing and documenting IQC.
· Performing at least one PT panel a year.
· Testers who are deemed not to perform well shall be given technical support through
supportive supervision or mentoring training approved by MOHCDGEC as stated in
relevant guidelines.
· Note More detailed information on certification can be obtained from the National HIV
Rapid Tester’s Certification Framework22
22
URT, MOHCDGEG National HIV rapid tester’s certification framework 2017
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7.6
Quality Assurance for HIV Counselling
The counselling component of HTS provides the client or patient with important information
regarding HIV prevention, care, treatment and support. The basic conditions to ensure that
high quality counselling services are being delivered are outlined in chapter three.
7.7
Quality Assurance for Logistics Management
The MOHCDGEC has the overall responsibility for QA of logistics in terms of forecasting,
procurement, distribution and supervision throughout the country. As the MOHCDGEC relies
on accurate reporting and record keeping by facilities, the following shall be observed:
· Each HTS facility shall identify a person responsible for quality HTS logistics who will:
· Ensure accurate and timely procurement of HIV-supplies from MSD, appropriate storage
of supplies and records keeping and reporting.
· Conduct realistic forecasting for HIV supplies (including test kits).
· Make timely procurement of supplies and maintain adequate stocks of unexpired supplies.
· Ensure proper storage of supplies and ensure timely delivery of HIV supplies to HTS
facilities in right quantities and conditions.
7.8
Quality Improvement Teams (QITs) for HTS
Quality improvement teams shall be responsible for overseeing the implementation of QA
strategies as stipulated in the Tanzania Quality Improvement Framework (2017). QI activities
shall be implemented at all levels from national to community level.
At the health facility, HTS providers shall form an active HTS Work Improvement Team (WIT),
whose role will be to address the needs of clients and HTS providers related to HTS in the
facility and the community they are serving. Individual HTS providers are also responsible for
the delivery of high quality HTS to clients and communities, according to defined standards.
The HTS WIT shall apply the QI Model to identify areas of HTS provision that are performing
well and areas that need improvement.
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CHAPTER EIGHT: HIV POST TEST CLUBS SERVICES
Preamble
An HIV Post Test Club (HPTCT) is a group of people who have tested for HIV and
know their HIV status. They form an organized group that enables them to come together to
talk about challenges, solutions, experiences and/or roles that they have in common without
being judged, blamed, stigmatized or isolated. The establishment of HPTCs is of paramount
importance as more people become aware of HIV and AIDS and the benefits of knowing their
HIV status. HPTCs provide benefits for those who test positive as well as those who test
negative. HPTCTs, also known as support groups, offer a holistic approach that can address
HIV in a broader context of peoples’ lives and thus mitigate the impact of HIV.
8.1
Rationale for HIV Post Test Clubs
HPTCs provide immediate connection from HIV testing point to other care, treatment and
support services. HPTCs members also learn different strategies on how to cope with their HIV
status. Experience sharing from each other is an added advantage for those who join HPTCs
for the first time after knowing their HIV status. In Tanzania, different forms of support services
have been established by different stakeholders. Implementation of the comprehensive
package of interventions in these clubs or support groups is expected to contribute to the
attainment of the global target of 90-90-90 by 202023.
8.2
Establishment of HIV Post Test Clubs
After post HIV testing counselling, service providers at HTS and CTCs shall mobilize and
sensitize clients to form or join HPTCs. Service providers shall also support the formation of
HPTCs by supporting the clubs with guidelines on how to run their meeting sessions, and
linking the clubs with district authorities and other support groups to get more guidance and
support on how to run a club
8.3
Types of HIV Post Test Clubs
There are various types of HPTCs including the following:
Health Facility-Based HPTCs
· Facility-based HPTCs are often organized as part of the integrated HIV services offered
by health facilities. These clubs are structured, scheduled and facilitated by a health
service provider and they provide group members with a direct link to other services (e.g.
counselling, psychosocial support, etc.). Service providers shall make sure that these
clubs are established and guided.
23
The UNAIDS 2016 – 2021 Strategy: On the Fast-Track to end AIDS.UNAID. Geneva
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Institution-Based HPTCs
Institution-based clubs are clubs that may be allied, but not directly associated with health
facility directly.
· Most of them are organized through community-based organizations, Institution-based or
Faith-based Clubs. Some of these organizations offer home-based, peer-facilitated clubs
or off-site locations. Service providers need to first establish their existence and then link
clients as necessary.
Professional HPTCs
· These clubs are not officially affiliated with an institution or governmental agency. Their
members belong to the same profession e.g. teachers, doctors, nurses, etc.
· They are organized by professionals who are HIV negative, who have had experience
with HIV, or are living with HIV. Others are facilitated by a social worker or healthcare
professional.
· They serve as a shelter for emotional support and interaction, encouraging members to
actively exchange ideas, advocate for their rights and pursue professional development.
The HTS and other health care providers must establish their existence and link clients as
necessary.
Community HPTCs
These are clubs that are based at the community and usually meet at a community site/centre
or a house. Most of them are organized by people who have tested HIV positive.
Individuals who test HIV negative or those who have had experience working with PLHIVs
should also be encouraged to either join the PLHIV clubs or form their own.
These clubs often serve as an emotional and economic empowerment club; encouraging
members to actively exchange ideas, advice and experiences.
HTS providers should:
· Support the establishment of community HPTCs in their catchment areas.
· Solicit and link to additional support from various extension workers including community
development officers, social workers, community health workers, and CBOs that provide
HIV and AIDS services.
Online HPTCs
Online clubs are not very common in Tanzania but they serve an important function for
PLHIVs who are either isolated by location or feel they can speak more freely and safely in an
anonymous environment. Online clubs are useful for disseminating HIV-related information
regardless of HIV status, offering valuable emotional and coping support, particularly in times
of crisis.
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· HTS providers should identify and map HPTCs in their catchment areas and link clients
as necessary.
8.4
Age categorization of HPTCs
The needs of HPTCs may differ by age and this has to be taken into consideration in the
formation of HIV post-test clubs. There are three main types of HPTCs for different age
categories, each type with different needs.
Paediatric clubs: Pre-school and low level class (0 to 9 years)
After post-test counselling, the HTS provider should discuss with the parent or guardian about
post-test clubs and solicit their consent if they agree to have their children enrolled in a HPTC.
Paediatric members MUST get consent from their parent or guardian.
Youth clubs: Early adolescence (10 to 14 years), adolescence (15 to 19 years) and young
adulthood (20-24 years)
· HTS providers shall seek parents’ or guardians’ consent for their adolescent child or
youth adult’s participation in an HPTC.
· They should ensure that members’ psychosocial and training needs are tailored
according to their respective age groups. Counsellors and facilitators providing services
to adolescents and minors should receive additional training on issues relating to the
establishment and operationalisation of youth clubs.
Adult clubs: (25 years and above)
HTS providers shall make sure that people 25 years of age and above can join adult clubs and
service providers shall group adult members into two age groups:
· 25-49 years
· 50 years and above
Pregnant and Lactating Mothers’ Clubs
These clubs are formed at ANC and PMTCT clinics. In some sites they are called Mother to
Mother (M2M) clubs where mothers meet to share their concerns.
In order to sustain these clubs, the health and HTS providers shall:
· Assist in the formulation of clubs at the ANC/PMTCT clinics.
· Support members by providing psychosocial support and skills for partner disclosure
counselling.
· Link mothers with community-based HIV services for continuity of care and adherence
counselling including counselling on safer infant feeding practices.
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CHAPTER NINE: HUMAN RESOURCES FOR HIV TESTING SERVICES
Preamble
Availability of well-trained HIV Testing Providers countrywide is critical for the provision of
high-quality HTS. HIV testing providers are required to be compassionate, dedicated, caring
individuals, as they have the very challenging and rewarding task of informing persons of
their HIV status. Standardized HTS training should cover how to correctly conduct full HTS
procedures, including collecting samples, performing RDTs following the national HIV testing
algorithm, as well as record-keeping and reporting. HIV testing providers should also be
oriented to these guidelines, up-to-date job aids, and SOPs. In addition, they should receive
on-going supportive supervision, mentorship and refresher training from HTS supervisors and
Health Management Teams (HMTs). This chapter describes the human resources component
in the provision of quality HTS at different levels.
9.1
Basic Educational and Ethical Requirements for HTS Providers
Educational requirements
HTS providers should have following educational qualifications:
· Secondary level education.
· Additional training or certification in health or related fields.
· Training and certification as an HTS provider based on the approved national HTS training
curricula with both didactic and practical components.
· Passed a skill-based proficiency test in order to be certified as HTS providers.
· Certified by the Tanzania Health Laboratory Practitioner Council to perform HIV testing.
Ethical Standards
HTS providers shall adhere to professional and ethical codes of conduct in all HTS approaches
and settings. A breach of these standards will result in disciplinary action as provided in The
HIV and AIDS (Prevention and Control) Act 2008.24
9.2
Training of HTS providers
MOHCDGEC through the NACP and Diagnostic Services section, are responsible for the
development of the HTS curriculum and training packages. The training materials have been
translated into Kiswahili so that their content is well understood by all HTS providers at all
levels of the health care delivery system. There shall be two main types of training; namely
basic training and ongoing refresher training.
24
HIV and AIDS (Prevention and Control) Act 2008
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Basic training
This shall be provided to identified HTS providers prior to their engagement in HTS. The main
types of basic trainings are: Client Initiated HIV Testing and Counselling (CITC) Training
HTS providers in an integrated or stand-alone CITC/VCT site, mobile/outreach, and home
based, work-place, or health facility HTS settings shall receive CITC training according to the
MOHCDGEC CITC training curriculum.
Training on Provider-Initiated Testing and Counselling (PITC)
PITC training shall be conducted for facility health care professionals to enable them provide
HTS as part of routine medical care.
HIV Rapid Testing Training
HIV rapid testing training and certification shall be provided to all identified HTS providers to
enable them perform HIV rapid testing. The training shall be provided as a module during the
CITC/PITC counsellors’ course to equip providers with the following:
· Skills to draw blood samples, conduct HIV rapid tests, and read, record and reporting of
HIV rapid test results, according to the national HIV testing algorithm.
· Skills to conduct quality assurance for HIV testing.
Note: All trainees shall be certified and licensed as HIV testers by the Tanzania Health
Laboratory Practitioner Council after they pass the competency test.
Additional training considerations for some population groups
Additional training curricula that supplements HTS provider skills are listed below. HTS
providers can take these trainings in their entirety or as refresher trainings.
HTS Training for Key and Vulnerable Populations (KVPs)
Health care workers and HTS providers shall receive standardized pre-service and refresher
training on providing HTS to KVPs. The 2017 guidelines for Key Populations shall be used for
training/re-training HTS providers.
HTS for Persons with Disabilities (PWD)
The MOHCDGEC shall coordinate the orientation of some of the HTS providers in knowledge
and skills to understand the use of sign and brail language and psychology of persons with
disabilities.
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9.3
Coordination and Harmonisation of HTS Training
In order to sustain the quality of HTS training and service provision, all training must be
conducted on the basis of the HTS training curriculum approved by the MOHCDGEC. In
addition to didactic training courses, practical, hands-on training with supportive supervision
and mentorship shall be provided as a pre-requisite to licensing. The MOHCDGEC through
NACP shall do the following:
· Maintain a team of master trainers to carry out all counsellor training using the approved
national training curricula and training materials to ensure standardisation and quality.
The counsellor master trainers must be qualified counsellors themselves and role models
of counselling ethics.
· Develop and carry out periodic reviews of HTS training curriculum and materials to be
used for the different courses.
· Provide a mechanism that will facilitate the identification and accreditation of institutions
(zonal), NGOs and FBOs and empower them to provide HTS training.
· Maintain a roster of mentors for HTS providers and conduct regular site visits preferably
every quarter. Teams should comprise of members from counselling, laboratory, quality
improvement and health information units.
· In collaboration with the HLPC, the NACP shall also coordinate auditing of HTS Providers
and sites outlined in chapter 7.
9.4
Comprehensive Supportive Supervision and Mentoring
Regular and appropriate comprehensive supportive supervision shall cover HTS, among other
things, to ensure high quality service provision and mentorship to HTS providers.
During supportive supervision, supervisors shall;
· Identify issues/challenges
· Empower health workers to improve on their performance by enhancing skills, knowledge
and abilities.
· Identify gaps that require further technical support.
· Facilitate the development of an action plan to address the identified problems.
· Follow up on the implementation of the previous action plan.
During mentorship, mentors shall;
· Mentor HTS providers according to the Manual of Comprehensive Supportive Supervision
and Mentoring of the HIV and AIDS Services (2017 Edition).
· Asses mentees’ performance and provide coaching as necessary;
· Support the application of theoretical learning to clinical /practical care;
· Prepare and agree on an action plan.
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9.5
HTS Providers Professional Growth and Development
As with any profession, HTS providers shall have opportunities for professional growth and
development to ensure an active and competent workforce. HTS managers and supervisors
shall facilitate the participation of HTS providers in the attainment of additional knowledge
and skills.
9.6
Occupational Health and Safety
All health management and HTS organizations have an obligation to care for their workers.
HTS providers are at risk of occupational exposure to HIV through needle stick injuries and
other workplace accidents. It is the responsibility of the management to do the following:
· Provide adequate training to all employees so that all HTS are conducted in accordance
with SOPs, minimizing risk of needle pricks. In addition, there should be, adequate
facilities for disposal of contaminated waste.
· Make PEP available to persons who experience occupational exposure to blood
contaminated needles or other sharp instruments.
· Ensure all HTS delivery sites have a copy of the MOHCDGEC PEP guidelines.
· Provide appropriate infrastructure for HTS e.g. good ventilation, comfortable workstations
with hand washing and sharps disposal facilities.
9.7
Task Sharing of HTS: Increasing the Scope of Trained Workers
Task sharing – the rational redistribution of tasks from “higher level” cadres of health-care
providers to other cadres – is a pragmatic response to health workforce shortages. The
MOHCDGEC Task Sharing Policy Guidelines for Health Sector Services in Tanzania (2016)
indicate that Social Welfare Assistants (SWAs) and CHWs can be allowed to support health
workers in the provision of HTS. For successful implementation of Task sharing in HTS;
· The MOHCDGEC shall develop/coordinate the development of the HTS training curriculum
and training materials for non-medical cadres.
· Existing and new HTS Master Trainers shall receive abbreviated training on the nonmedical HTS curriculum before they train non-medical cadres.
· Master Trainers must ensure that the training provided to non-medical HTS providers is
practical to enable trainees undertake tasks such as provision of quality HTS, linkage to
care, adherence counselling, post-test support and group management.
· The selection of non-medical HTS trainees shall ensure the selected trainees have a
professional conduct, knowledge, and skills in dealing with sensitive issues, respect for
confidentiality and an ability to listen.
· The MOHCDGEC (NACP) shall develop and distribute job aides and SOPs (preferably
translated into Kiswahili).
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10.1
Required HTS Supplies
Accurate record maintenance and reporting of the number of clients attended and specific
services offered are among important factors that help to establish types and quantities of
supplies needed at each HTS site. Generally, the commodities and supplies listed below
should be sufficiently available during the provision of HIV rapid testing for all approaches and
in all settings:
· HIV rapid test kits and accessories
· Lancets and capillary tubes if not included in the DBS or test kit
· Timer or stop watch for ensuring test kits are read within the recommended time frame
· Needles and syringes
· Other medical consumables, such as swabs, spirit, disinfectants, sodium hydrochloride
· Gloves and other supplies needed for universal precautions
· Sharps disposal containers / safety boxes
· Waste disposal (colour coded) containers and their liners
· Registers for record keeping
· Reporting forms (logbook)
· Condoms – both female and male
· Penile and pelvic models for demonstration of condom use
In addition to standard HTS supplies, the following supplies shall be used by HTS providers
during home-based, outreach and mobile HTS services:
· Boxes for carrying test kits and ensuring that the temperatures do not exceed (2⁰-27⁰
C)
· Plastic sheets and testing surface such as a plastic cutting board
· Portable sharps disposal containers and biohazard waste containers
· Torches, umbrellas, rain coats, gum boots
· Hand washing equipment and water (Soap and/or hand sanitizer, paper towels)
· Backpack for carrying supplies
· Water bottle for storing drinking water
· Mobile phone for each home-based HTS team in case of an emergency
· Job aids and home-based HTS protocols
10.2
HIV Test Kits
All HIV test kits procured and used for HTS in Tanzania must be approved and registered
by the MOHCDGEC through the Tanzania Food and Drug Authority (TFDA). Only HIV test
kits approved by TFDA and included in the National HIV Testing Algorithm shall be used for
HIV testing. Table 10.1 shows the currently recommended HIV Test kits, storage temperature
requirements, maximum shelf-life and packaging
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NATIONAL AIDS CONTROL PROGRAMME
Table 10.1: The Current Recommended HIV Test Kits
S/N
Test
1
SD BIOLINE HIV I/2-3.0 (Rapid test kit)
2
Uni-Gold HIV Test
The MSD shall ensure newly received batches of HIV test kits are quality checked by the NHLQATC before their distribution to sites. This requirement applies to all sites providing HTS in
both public and private health facilities. Public facilities and approved private and faith based
facilities may receive HIV rapid test kits from MOHCDGEC through MSD.
10.3
Quantification
Quantification is the general term for the process of estimating the quantities of specific
equipment, laboratory reagents, and consumable medical supplies required to serve
customers in a health program for a given period of time.
Quantification for HIV test kits involves:
I.
Preparation
This includes defining the scope and purpose and collecting required data directly from
health facility reports or through HMIS or eLMIS.
II.
Forecasting
This includes organizing and analysing data, selecting a forecasting method, building
forecasting methods and calculating forecasted consumption for each product.
III.
Supply planning
This includes but is not limited to organizing and analysing data, building supply planning
assumptions and developing a supply plan.
Roles and Responsibilities – Site level
Forecasting for test kits and other supplies depends on accurate and timely reporting from all
HTS sites.
I.
HTS sites shall report the requisite consumption data to the DMO. This information shall
include the number of test kits used each month, quantities in stock and the number of
test kits expired each month.
II.
HTS sites shall also note if there is a need for more kits in a particular month due to
planned outreach HTS events, other mass HTS services, or increased capacity for
providing HTS.
III.
HTS sites shall consider the lead period between ordering and delivery of supplies.
IV.
HTS sites shall observe the established maximum and minimum levels for inventory.
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10.4
Procurement
All HIV tests and related commodities are procured centrally through NACP and received by
MSD. Following the reporting procedures outlined above, sites will request test kits and other
HTS supplies from the DMO and the DMO shall request supplies directly from MSD. Medical
officers, and in-charges of regional and district hospitals shall order their own supplies.
10.5
Receiving, Storage & Distribution
At national level, HIV test kits are received and inspected centrally then distributed to
MSD’s eight zones and two sales points. MSD zonal stores and all facilities/sites providing
HIV testing services shall keep an accurate inventory of their supplies and commodities.
They should also ensure that HIV test kits and other commodities are stored properly and
used before their expiry date by adhering to the First to Expire First Out (FEFO) rule during
issuance. HIV tests and commodities must be stored as specified in the manufacturers
recommended storage conditions inserted in the HIV test kits and SOPs.
At every facility where commodities are stored, a designated person shall ensure accurate
and timely ordering of HIV testing supplies, appropriate storage including accurate stock
rotation, record keeping and reporting. This person shall be accountable for maintaining
quality HIV testing supplies and shall promptly report any problems with the management
of commodities to the site supervisor or in-charge of the facility. MSD is responsible for
the distribution of test kits and other supplies to all health facilities in accordance with the
Integrated Logistic System (ILS) Protocol.
Roles and Responsibilities - National level
The MOHCDGEC forecasts needs, allocates central funds, procures and supervises
MSD Central/zones receive the right supplies of the right quality in the right quantities and at
the right time. They then store and distribute the same to the right place.
The Hospital level prepares orders, receives supplies of the right quality in the right quantities
and at the right time and serves clients.
The District level reviews and approves orders from dispensaries and health centres,
allocates local funds, receives right supplies of the right quality in the right quantities and at
the right time and delivers the same to facilities/sites while storing in transit supplies.
The Site level prepares orders, receives right supplies of the right quality in the right quantities
and at the right time and serves clients.
10.6
Monitoring & Evaluation of HTS Commodities
NACP shall conduct yearly audits of the commodity management systems for HIV test kits
and other essential supplies. This will facilitate the determination of the effectiveness of the
process and prevent mismanagement of HTS commodities and supplies.
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CHAPTER ELEVEN: MONITORING AND EVALUATION
Preamble
Monitoring and Evaluation (M&E) is an essential component of quality HIV testing and services.
It provides reports on key indicators that allows programmers to track trends in HTS inputs,
processes, outputs, outcomes and impacts which are useful for informed strategic planning.
Monitoring involves routine collection, analysis and reporting of data to assess progress
against set targets. It aims to establish trends, patterns, adaptation of strategies so as to
inform decisions for programme management.
Evaluation includes assessment of ongoing or completed projects, programmes or policies,
their design, implementation and results. The aim of evaluating HTS is to determine the
relevance and fulfilment of objectives, developmental efficiency, effectiveness, impact and
sustainability.
The MOHCDGEC through NACP shall ensure that National HTS M&E tools are used at all
HTS sites for data collection and reporting on key indicators. Data quality shall be assessed
regularly and improvement plans developed as needed by supervisors as part of QA systems.
It shall also conduct periodic reviews/evaluations to assess HTS outcomes and impacts more
rigorously. These evaluations may provide key information on specific elements of HTS that
are successful or where modifications need to be made.
11.1
HTS Data Sources
HIV testing data are generated from various service points as follows:
a) Clinical departments (e.g. OPD, IPD, theatre, dental clinic, eye clinic, TB/HIV clinic,
laboratory, etc.) within hospitals, health centres and dispensaries,
b) Gender Based Violence (GBV) Services,
c) PEP Services,
d) PMTCT: ANC, labour and delivery, postnatal, and family planning
e) VMMC Services,
f)
Community Based HIV Services (CBHS),
g) Standalone Voluntary Counselling and Testing (VCT) Centres,
h) KVP Services,
j)
11.2
ART CTCs (may be stand alone or integrated)
Data Collection
Client or patient information shall be collected during every HTS encounter in all approaches
and settings using MOHCDGEC approved HTS data collection tools:
· National HTS registers to record initial testing and retesting for verification for collecting
both demographic and HIV testing information
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· HTS reporting tools to be used at designated periods (i.e. on monthly basis).
· Accurate recording on and completion of data collection tools shall be ensured. All HTS
providers shall be trained on data variables and on the necessity of completing data
collection tools for each client or patient before they leave the HTS room. However,
collection of such information shall not interfere with the counselling process.
· HTS clients or patients shall be informed that information captured on the data collection
tools is confidential.
11.3
Data Compilation
These guidelines contain several new innovative approaches and settings for the provision of
HTS which have necessitated a revision of data collection and reporting. Health Management
teams and HTS supervisors must ensure that all HTS providers at all levels are trained/
supervised and mentored on these changes. They should utilize the data they collect for
planning purposes and identification of areas for improving service provision at their individual
sites. The changes are elaborated in Table 11.1.
11.4
Data Reporting and Feedback
At the end of every month, HTS sites shall aggregate data from the registers and enter this
information into the standard monthly HTS reporting form as outlined below:
· Monthly reporting forms shall be sent to the DMO’s Office, through DACCs by the 7th day
of the month following the month of data collection.
· The DMO/DACC will receive, validate, and enter data into the District Health Information
System (DHIS-2) for the data to be available to the RMO’s Office and national level.
· The DMO’s and RMO’s offices as well as NACP will validate the data and send feedback
to the lower level, as such, the district level shall provide feedback to the HTS site, regional
level shall provide feedback to the district; and the national level shall provide feedback
to the region.
· Annual reports will be developed and disseminated to all relevant stakeholders, including
HTS sites.
· In addition to national level reports, all reporting levels should retain their copies and
utilize them for planning purposes. Feedback on data collection, data quality, or trends
in data outcomes shall be communicated back to HTS sites, districts and regions, as
outlined in the data flow system in Figure 11.
11.5
Data Analysis and Interpretation
HTS data are analysed regularly, on demand and on an annual basis to produce reports. The
outputs in these reports, together with activity-specific reports are aligned with national HTS
input, process, output and outcome indicators.
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Selection and Use of Indicators
These revised guidelines have recommended multiple HTS approaches to maximize HTS
coverage and uptake. Disaggregating service statistics by HIV diagnosis, by service delivery
point and/or by population subgroups shall help when setting targets for HTS and linkages into
care, treatment, and prevention and support services. Disaggregation of HTS data at national
level is important to ensure that critical populations are accessing HTS. Such disaggregation’s
are exemplified in Box No. 11.1
Table 11.1: HTS Data Compilation
Testing and data compilation scenarios
Final report sent to NACP
PITC data
PITC through DHIS2
All clinical departments (as listed above) within all health Compile as one report for
facilities, GBV services, PEP & PrEP services, Postnatal each facility
services, Family Planning services, VMMC services, ART
clinics, Community HTS and KVPs services such as those
provided to Adolescents Girls and Young women (AGYW),
Sex Workers (SW), Males having Sex with other Males
(MSM), Injecting Drug Users (IDU). All the testing data
from all of these points, if within the same facility, will be
combined as one report from each facility.
National HTS Register shall be used to record Retesting for Prepare
data
separately.
verification at all ART initiating sites. Reports of retesting for Include the data in the monthly
verification shall be prepared separately and be included in facility report for HTS.
a comprehensive monthly facility report for HTS.
Antenatal
MTUHA-6
Labour & Delivery clinics
MTUHA-12
ANC and Labour clinics shall use HIV testing registers (both Testing data will be entered
for initial testing and retesting for verification)
into DHIS2 through the PITC
channel
Standalone CITC Clinics and Private Health Facilities shall Report into DHIS2 through the
use the national HIV testing registers for testing and re- CITC channel
testing data, and compile report using monthly facility
report for HTS.
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HIV testing at the community shall be done using the HIV Report into DHIS through
testing registers for initial testing and compile monthly the Community Based HIV
summary HTS report
Services (CBHS) channel.
Retesting for verification registers shall only be used in Prepare
data
separately.
the community if ARVs would be initiated by approved Include the data in the monthly
personnel at the community.
facility report for HTS.
HTS Global Indicators
Two indicators are adopted from WHOs recommendation for re-testing all newly diagnosed
persons to verify the results before starting ART. These indicators shall read;
· % of persons linked and re-tested (verified) HIV positive at care and treatment clinics
Numerator: Number of person linked and re-tested positive (newly diagnosed)
Denominator: Total number of newly diagnosed persons linked and re-tested
· % of persons linked and re-tested (verified) HIV negative at care and treatment clinics
Numerator: Number of person linked and re-tested as HIV negative
Denominator: Total number of persons linked and re-tested for HIV at CTC.
Box 11.1 Categories for disaggregation of variables recommended by WHO
Below is an exemplified list of variables for disaggregating HTS data:
·
·
·
·
·
·


Age:<1, 1−9, 10−14, 15–19, 20−24, 25−49, 50+
Sex: male, female
Test result: HIV-positive, HIV-negative, Inconclusive
Population: pregnant or breastfeeding women, partners, key populations;
sero-discordant couples, infants and children, adolescents, TB/STI clients/
patients linkages.
Geographic area: district, region, province, facility, community
Service delivery point:
Facility-based, for example, ANC clinics, outpatient care, inpatient care, TB
clinics, STI clinics, HTS clinics, integrated HTS
Community-based, for example, home-based, door-to-door, mobile outreach
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Districts and Regions
At district and regional levels, HTS managers shall utilize data for:
· Guiding programme planning and implementation;
· Resource allocation to meet programme goals.
· Determining sites that are successful and those that may need additional supportive
supervision.
· Motivational support to sites that are performing well e.g. a letter of recognition or
congratulatory letter. This could be done bi-annually.
MOHCDGEC- National HIV/HTS
The NACP shall use HTS data for some of the following:
· Answering critical questions about Tanzania’s HIV epidemic in a local, regional, national
context.
· Determining geographic areas that shall be prioritized for HTS service delivery using
different HTS approaches.
· Documentation and dissemination as outlined in sections 11.4.4 and 11.4.5
11.7
Documentation
· The MOHCDGEC encourages continuous documentation of M&E best practices, lessons
learned and publications of HTS data. Nonetheless, scientific publications in any format
e.g. papers aimed for peer review journals, abstracts, conference proceedings, etc. that
are based on national HTS data must seek the prior approval of the MOHCDGEC.
· Moreover, where appropriate, other national ethical approval entities such as the National
Institute of Medical Research (NIMR) and independent academic ethical committees shall
also be engaged.
Sharing of data summary reports
Data summary reports and resulting information shall be shared with stakeholders at all levels
as follows:
· DMOs shall share these reports with HTS sites, Local Government Authorities, District
Commissioners, District Executive Directors and stakeholders in the district,
· RMOs shall share their reports with all districts within their region, the Regional
Commissioner, the Regional Administrative Secretary and key stakeholders in the region,
· The NACP Programme Manager shall share reports with RMOs, TACAIDS, other ministries,
implementing partners, development partners and other key national stakeholders,
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11.8
Data Storage and Security
Both paper based and electronic data collected at HTS sites are confidential and therefore: · All HTS providers shall treat clients’ records with the same level of protection as all other
medical records.
· HIV testing registers shall be stored at HTS sites for as long as permitted both by facility
and the MOHCDGEC agreed archiving standards.
11.9
HTS Target Setting
National targets shall be developed on the basis of contributions from regional and district
levels. HTS sites shall also establish their targets, which shall contribute to district set targets.
Relevant providers at all levels shall be trained to understand the set targets, so as to avoid
possibilities of under or over-targeting at all levels.
Stakeholders’ Support for M&E Roles
The successful implementation of the HTS monitoring system requires the concerted efforts of
different stakeholders at all levels of the health care delivery cascade i.e. national to community
level.
National Level Support for M&E
· The M&E section of NACP maintains a secure electronic system with overtly updated,
summary-level data based on information received from site, district, and regional levels.
NACP’s M&E for HTS is centered on the following core activities:
· Maintain support to prevent tempering of micro-databases at all testing sites
· Analyze, interpret, provide feedback and disseminate HTS information to all stakeholders
· Guide supportive supervision for M&E activities at regional, district and HTS sites,
· Coordinate training of HTS providers on the importance of data collection, analysis and
use,
· Routinely review national HTS M&E tools
· Ensure credibility of reported data through guided data quality assessments at all levels
HIV and AIDS Implementing Partners
· Comply, develop and scale-up the national HTS M&E system
· Support regions, councils and health facilities on the analysis, dissemination and use of
quality data
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Regional and Council Level Support for M&E
Slight variations may exist with regard to M&E roles and responsibilities of regional and council
stakeholders. The shared roles and responsibilities of regional and council stakeholders
include but are not limited to:
· Building the capacity of primary health facilities and standalone sites on the management
(including recording and reporting and data quality reviews) of HIV testing data.
· Coordinate trainings of service providers at all testing points on HIV and AIDS HTS M&E
system.
· Mobilize resources at those levels to strengthen the HTS M& E system.
· Disseminate HTS data at regional and council level, and
· Strengthening communication with national level regarding all HIV and AIDS M&E matters
at regional and council level.
Health Facility level
· Ensure availability and effective use of the recording and reporting tools for HIV and AIDS
testing services,
· Ensure timely entry into DHIS2 of HTS reports and submission to the DMO’s office,
· Report all challenges faced by the health facility in all HIV and AIDS HTS M&E systems
to the DMO,
· Conduct and report on internal data quality assessments on a quarterly basis.
11.10
Monitoring and Evaluation of HIV Post Test Clubs
Monitoring and evaluation of HPTCs helps to assess operations, track progress and facilitate
decision making for improving service. Every HPTC Cluster level will establish their M&E plan
reflecting the operational objectives and activities of the cluster below it, from national down
to ward level.
National, Regional, and District Authorities
· Conduct baseline study or use existing information as baseline reference,
· Involve all stakeholders based on the principles stated in Public Private Partnership (PPP)
e.g. ensure ethical consideration to respect and protect the rights and welfare of all those
involved in HPTC operations,
· Design a specific methodology to gather information about HPTC establishment and
operationalisation that links specific goals and objectives to result pathways.
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CHAPTER TWELVE: IMPLEMENTATION FRAMEWORK
Preamble
Delivery of HTS in Tanzania relies on the participation and coordination of many authorities
within the Government structure, from the national level to primary health facilities. Additionally,
the role of Non-Governmental Organizations (NGOs), Private Health Facilities including
faith-based organizations (FBOs) and Community-Based Organizations (CBOs) is critical
to improving access to quality HTS for all Tanzanians. This chapter outlines the roles and
responsibilities for HTS provision at different levels of implementation.
12.1
National Level
The Tanzania Commission for AIDS (TACAIDS) provides overall coordination of the multisectorial response to HIV and AIDS in the country.
The MOHCDGEC, through the NACP, coordinates the implementation of technical aspects of
HIV and AIDS prevention, care, treatment and support programmes, including HTS.
The President’s Office Regional Authority and Local Government (PO-RALG), manages
planning and implementation of the HIV and AIDS prevention, care, treatment and support
programmes, including HTS.
The Medical Stores Department (MSD) is responsible for procurement, storage and distribution
of HIV and AIDS commodities and supplies.
The National Health Laboratory and Quality Assurance Training Centre (NHL-QATC) is
responsible for quality assurance and quality improvement of HIV testing.
The NACP convenes an HTS Technical Working Group (TWG) comprised of technical experts
from MOHCDGEC, representatives from regional and district health authorities, bilateral and
multilateral agencies, international and national NGOs, academia and other implementing
partners, which meets regularly and provides technical support in the following key areas:
· Policy formulation and establishment of strategic plans regarding HTS.
· Appropriate dissemination and implementation of HTS policies.
· Advising on HTS roll out and scale up.
· Management of HTS commodities.
· Coordination, monitoring of HTS performance and assessment of the quality of service
delivery.
· Capacity building for HTS service providers and systems.
· Improvement and management of national data collection and database.
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· Operational and health systems research including identification of priority research
agenda on HPTC services and facilitating their implementation.
· Development of best practices in HTS in collaboration with international and national
partners and HPTC coordination and service delivery.
· Coordination of partners involved in HTS and HPTC services.
· Development and review of new IEC materials.
· Approval of IEC materials before production and dissemination.
With regards to HPTC services:
· The NACP shall promote HPTCs and coordinate all stakeholders involved in the provision
of HPTC services to promote equity in geographical coverage.
· NACP shall also set targets and strategies to ensure establishment, monitoring and
evaluation of HPTCs.
12.2
Regional Level
The Regional Medical Officer (RMO) is the overall overseer of all HIV and AIDS services in the
region, the RMO works with the Regional Health Management Team (RHMT), receiving technical input from Regional AIDS Coordinator and Regional HTS Coordinator. The RMO carriers
out the following roles: · Dissemination and enforcement of MOHCDGEC policies, guidelines and standards
including those related to promotion of HTS services.
· Coordination and supervision of HTS service performance.
· Capacity building, including initiation of staff deployment, training, and certification.
· Monitoring and evaluating of HTS.
· Facilitates reporting from district to national level and vice versa.
· Comprehensive supportive supervision and mentoring of HTS service providers and
HPTC clusters.
· Laboratory support for quality assurance (QA) of HIV testing.
· Networking and coordination of stakeholders at the regional level
· Resource mobilization and accountability.
· Ensuring availability of HIV testing supplies and commodities throughout the region.
· Review of new IEC materials and forwarding them to NACP for approval before they are
disseminated to the public. This includes materials related to the promotion of HPTC
services.
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12.3
District Level
The District Medical Officer (DMO) is the overall overseer of all HIV and AIDS services in the
district, as such, they have the same roles listed for the RMO in Section 12.2 but at the level
of the district. They are supported by the District AIDS Coordinators (DACs) and the District
HTS focal persons. In addition, DMOs have the responsibility of ensuring that HIV and AIDS
interventions are incorporated into the Comprehensive Council Health Plans (CCHPs).
12.4
Facility Level
The successful implementation of HTS relies on the implementation of quality HTS at primary
health facility levels. The following roles are carried out by HTS providers under the accountability of the health facility in charge: ·
·
·
·
·
·
·
·
·
·
·
·
·
·
Provision of quality HTS to clients and patients as directed by the DMO;
Putting in place quality assurance (QA) measures for HIV testing services including: Abiding to national standards for HTS site set up.
Conducting regular client exit interviews.
Validating all new batches of HIV Rapid Test Kits (HRTK) before use.
Conducting all HIV tests according to national HIV testing algorithm and SOPs.
Recording clients’ and testing data accurately, using nationally approved tools
Taking part in regular EQA activities
Managing HTS commodities following the principle of “first in first out” and ensuring
timely reporting of stock outs.
Managing safe disposal of medical waste generated at the HTS site.
Linking clients and patients from HTS to appropriate follow-up services, as needed;
Preparing accurate and timely reports for the health facility and district levels.
Mobilizing communities on HTS, raising awareness, and providing HTS education and
information material.
Participating in relevant stakeholder forums and planning meetings.
Roles and responsibilities of primary health facilities in relation to HPTCs
Primary service providers in all facilities with VCT, CTC and PITC shall:
· Assist in mobilizing and sensitizing clients to join HPTC at the health facility or at
community level.
· Provide space for HPTC meetings and for their activities.
· Link HPTC with available resources from private and public partners.
· Support HPTC with referrals to relevant level of service.
· Support HPTC to have Income Generating Activities (IGAs).
· Support counsellors to provide home based testing and counselling (HBTC).
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NATIONAL AIDS CONTROL PROGRAMME
Health Facility In-charges, Assistant Social Welfare Officers, and Ward Health Officers shall
collaborate with district authorities to support the formation of Ward HPTC clusters and support the clusters to have a constitution and be registered as CBOs.
12.5
Roles and responsibilities of HTS providers at community level
Successful implementation of an HTS relies on the provision of quality HTS at the outreach
site/mobile and home based. HTS providers shall conduct the following activities at the HTS
outreach site level under the accountability of the health facility in charge: · Provide HTS education and information, raise awareness and mobilize communities for
HTS services.
· Provide quality HTS to clients and patients.
· Manage outreach site-level HTS logistics and commodities;
· Prepare accurate reports and ensure their timely submission to the health facility.
· Make referrals from the community to the nearby health facility.
· Manage safe disposal of medical waste generated at the community HTC sites.
· Participate in relevant stakeholders’ forums and meetings including planning for HTS and
provide community perspective of HTS.
12.6
HIV Testing and Counselling Focal persons
The MOHCDGEC has instituted HTS focal persons at all levels to work closely with Regional/District AIDS Coordinators and Laboratory HIV focal persons.
Their roles are outlined below.
Regional/District HTS focal persons
· Ensure the availability of adequate commodities, supplies and personnel for HTS.
· Set up Regional/District capacity building programmes in consultation with RHMTs/CH
MTs.
· Develop and coordinate the network of providers and hold quarterly meetings involving
HTS stakeholders.
· In consultation with RHMTs/CHMTs, identify and recommend HTS supervisors for training.
· Provide feedback to the facility management and to the RHMT/CHMT on the performance
of HTS.
· Compile and submit monthly and quarterly reports.
· Ensure HTS providers are trained according to the approved requirement and enrolled
into proficiency testing programme and corrective measures taken whenever necessary.
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80
APPENDIX 2: REFERRAL FORM
80
APPENDIX 4: COUNCIL MONTHLY SUMMARY REPORT
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NATIONAL AIDS CONTROL PROGRAMME
APPENDIX 5: INDEX CLIENT ELICITATION AND OUTCOME FORM
NATIONAL AIDS CONTROL PROGRAMME
APPENDIX 6: HTS Service Delivery Models
Service Delivery Models are designed using the building blocks approach with four delivery
components: (i) the types of services delivered; (ii) the location of service delivery; (iii) the
provider of services; and (iv) the frequency of services. The four components are guided by
the following key questions:
When is care provided?
Where is care provided?
Who is providing care?
What type of care or services are provided?
Differentiated models of HTS delivery should be designed and implemented as a direct
response to specific challenges or barriers identified for clients and/or health care workers.
Service Delivery Models (SDMs) for differentiated HTS
The Service Delivery Model for differentiated HTS is a client centred approach that simplifies
and adapts HIV services for different population groups
84
Select examples of how HIV testing has been differentiated
Source: Adapted from International AIDS Society (IAS). Differentiated Service Delivery for
HIV: A decision framework for HIV Testing Services. July 2018
Facility based testing:
PITC should be offered at
all entry points of the health
facilities, including OPD, IPD
(malnutrition and paediatric
wards), CTC, TB, STI, and
RCH/PMTCT.
Facility and community based
index client testing should be
offered at all facilities.
Targeted sub-population
testing should be offered as
community based outreach
testing monthly at all facilities.
WHERE
Targeted outreach testing for
schools and colleges, street
children and orphanages
should be included in monthly
outreach planning.
Special considerations for children and adolescents
HTS should be
available in all
facilities during
government defined
opening hours. HTS
should be available
24 hours (overnight
and weekends) for
facilities providing
maternity and
inpatient care.
General Population
WHEN
85
workers should be trained to prepare DBS
samples for EID testing.
All facilities should ensure there is always
a HCW on duty that has been trained to
provide HTS and prepare DBS samples for
EID testing.
Trained health care workers should perform
HTS and EID DBS during mobile outreach
activities.
All cadres of existing health care
Expert adolescent peers should be trained
to mobilise adolescents for testing.
Expert clients should be trained to mobilise
communities to access HTS.
All cadres of existing health care workers
should be eligible to be trained to perform
HTS.
Every facility must ensure that there is
always a HCW on duty who has been
trained to perform HTS.
WHO
APPENDIX 7: Differentiated HIV Testing Services in different populations
Integrate EID DBS and HTS
into outreach Health services
e.g. EPI, TB, NCD and
Family Planning services
Integrated screening
approaches should be
implemented in community
testing strategies. This may
include HIV testing, TB
and STI screening, blood
pressure and blood glucose
checks, and nutrition
assessments.
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NATIONAL AIDS CONTROL PROGRAMME
·
·
·
Districts should map the
KVP peers should be trained to mobilise
locations where specific KVP
their communities to access HTS.
will access HTS.
Targeted outreach testing from
the facility serving the defined
locations.
KVPs should be offered
an integrated package of
services with HTS e.g. for
female sex workers, HTS,
Condom distribution, Family
Planning, STI screening and
treatment, GBV services,
and Prevention services
(PEP).
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All HIV positive clients identified at an HTS site should be guided (with their consent) to the CTC for enrolment into ART care.
This should ideally be done by the HTS/Health care provider who has performed the test or by a community HTS provider.
All HIV positive clients identified should be linked (with their consent), with a community health worker or community HTS
provider. A referral form should be completed for anyone testing positive in the community and the respective client should be
encouraged to attend the CTC at a facility of their choice.
Any client who has tested HIV positive should be asked for their consent to be traced. Any client who has not been linked to care
after one month should be traced. Tracing should initially be done by phone followed by a home visit.
Linkage to care
Key and vulnerable
populations should
be consulted to
determine the most
appropriate time
to offer community
or facility based
HTS e.g. moonlight
testing for female
sex workers.
Special considerations for key and vulnerable populations (KVPS)
Re-testing of HIV negative
pregnant and breastfeeding
women should be integrated
in facility and outreach EPI
activities.
Special considerations for pregnant and breastfeeding women
NATIONAL AIDS CONTROL PROGRAMME
NATIONAL AIDS CONTROL PROGRAMME
APPENDIX 8: SOP for Index Client Testing and Partner Notification
INDEX CLIENTS TESTING AND PARTNER NOTIFICATION SERVICES PACKAGE
During pre-test information/counselling, providers should:
• Explain the importance of ensuring that all partners get tested for HIV.
• HIV-positive partners can start on HIV treatment to keep them healthy and reduce
the risk of passing HIV to other sex partners and/or children.
• HIV-negative partners can access HIV prevention services to help them remain
HIV-negative, including condoms, pre-exposure prophylaxis (PrEP), and male
circumcision.
• Inform the index client that:
• We are Offering Partner Testing Services to assist the client to contact their partners
so that these partners can learn their HIV status.
• The service is offered because disclosure of HIV status to partners can be difficult.
• It is important to provide a list the names and contacts of their sexual partners and
people they have shared needles with.
• Names of any children who may need an HIV test should be provided to ensure they
too are offered the necessary tests and/or services.
During post-test counselling: • Remind the client of the importance of partner testing using information from the
section above.
• Inform the client that there are 4 options for contacting their partners: 1. Client to contact their partner(s) to let them know that they should be tested for
HIV;
2. The healthcare providers to contact the client’s partners directly, without telling
them the client’s name (this will be done anonymously);
3. Client to contact their partner within a certain time period, after which the
provider will offer assistance if the partner has not been tested;
4. The counsellor/provider to sit with the client and their partner(s) and support the
client as they tell their partner(s) about their HIV infection.
• If the client chooses option (3), they will have 4 weeks to bring in or refer their
partner(s) for HTS.
• If the partner does not come in for HTS after 4 weeks, then the provider will contact
the index client for permission to contact their partner(s).
NATIONAL AIDS CONTROL PROGRAMME
Inform the index client that:
• All information will be kept confidential; meaning that:
• Partners will NOT be told the index client’s name or test results.
• The index client will NOT be told the HIV test results of their partner(s) or whether or
not their partner(s) actually tested for HIV.
• Contacts will only be reached after receiving index client consent.
• HIV positive tested clients will continue to receive the same level of care at this health
facility regardless of whether they choose to participate in partner notification services.
• The index client shall be given the opportunity to ask questions and give verbal consent to continue. Once the index client provides consent this should be documented
in the remarks column of the HTS register as well as in the client HIV referral form.
Contact tracing and documentation has been incorporated in the national CTC2 forms.